A client requests heat therapy for lower back pain. Which action should the nurse take?

Demonstrate use of temperature control.

Use moist towel as a skin barrier.

Assess skin every 30 minutes after application.

Obtain a prescription for heat application.

Answer and Explanation

The Correct Answer is D

Choice A reason: Demonstrating temperature control is relevant but secondary to obtaining a prescription. Heat therapy increases blood flow, relaxing muscles, but requires medical approval to ensure safety, as improper use risks burns or exacerbates conditions like inflammation. A prescription confirms appropriateness, making this action premature without authorization.

Choice B reason: Using a moist towel as a barrier enhances heat conduction but is not the first step. Heat therapy requires a prescription to verify its suitability, as it may worsen conditions like acute inflammation. Without medical approval, applying heat risks harm, making this action inappropriate before confirming the order.

Choice C reason: Assessing skin every 30 minutes monitors for burns but follows prescription and application. Heat therapy vasodilates vessels, relieving pain, but requires a physician’s order to ensure it’s indicated. Starting therapy without authorization risks adverse effects, like tissue damage, making skin assessment secondary to obtaining a prescription.

Choice D reason: Obtaining a prescription is the first action, as heat therapy requires medical approval to ensure it’s safe and indicated for lower back pain. Heat increases blood flow, but conditions like malignancy or acute injury contraindicate it. A prescription ensures appropriate use, preventing harm, making this the priority action.

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Correct Answer is A

Explanation

Choice A reason: Asking how the client feels about their boss’s behavior promotes therapeutic communication by encouraging emotional expression. This open-ended question facilitates self-reflection, builds trust, and allows the nurse to assess the client’s emotional state, guiding further support. It aligns with patient-centered care and psychosocial assessment principles in nursing practice.

Choice B reason: Acknowledging the difficulty of the situation shows empathy but assumes the client’s feelings, potentially limiting exploration. An open-ended question better elicits the client’s perspective, fostering deeper dialogue. This response, while supportive, is less effective for assessing emotional impact, as it does not encourage the client to elaborate, per therapeutic communication guidelines.

Choice C reason: Suggesting a different approach offers advice prematurely, which may dismiss the client’s feelings. Therapeutic communication prioritizes exploring emotions before problem-solving. This response risks alienating the client by implying they are responsible for the issue, rather than validating their experience, per principles of active listening and patient-centered care in nursing.

Choice D reason: Asking why the client allows the boss to upset them is judgmental, implying fault. This closed question hinders therapeutic communication, potentially making the client defensive. A non-judgmental, open-ended response better supports emotional expression and trust, aligning with psychosocial care and effective nurse-client relationship principles in clinical practice.

A. Wait to obtain the specimen until observable blood is present. B. Withhold specimen collection until tarry black stool is observed. C. Obtain the specimen from the client’s current bowel movement. D. Contact the healthcare provider before obtaining the specimen.

Correct Answer is C

Explanation

Choice A reason: Waiting for visible blood is incorrect, as occult blood tests detect microscopic bleeding not visible to the eye. Soft, light brown stool is suitable for testing. Delaying risks missing early gastrointestinal bleeding, per diagnostic testing and colorectal screening protocols in nursing practice.

Choice B reason: Withholding collection until tarry black stool appears is wrong, as occult blood tests identify hidden blood, not overt melena. Light brown stool is appropriate for testing. Waiting delays diagnosis of potential bleeding sources, per gastrointestinal assessment and occult blood testing standards in medical care.

Choice C reason: Obtaining the specimen from the current soft, solid, light brown stool is correct, as occult blood tests detect microscopic blood in normal-appearing feces. This ensures timely screening for gastrointestinal bleeding, guiding diagnosis and treatment, per evidence-based practice and diagnostic testing protocols in nursing.

Choice D reason: Contacting the provider before collecting the specimen is unnecessary, as soft, light brown stool is suitable for occult blood testing. Routine collection is within nursing scope, and delays may miss early bleeding. This aligns with standard diagnostic procedures, per gastrointestinal and nursing care guidelines.

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A client requests heat therapy for lower back pain. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client tells the nurse how they hate the way their boss orders them around and never listens to their suggestions. Which response is best for the nurse to provide?

Correct Answer is A

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client’s feces is soft, solid, and light brown. Which action should the nurse implement?

Correct Answer is C

Explanation

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