A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

Asking the client to rate the pain

Having the client perform range-of-motion of the affected arm

Monitoring the client's pulse rate

Inspecting the site for reduced swelling

Answer and Explanation

The Correct Answer is A

A. Asking the client to rate the pain: Pain rating provides a subjective measure of the intervention’s effectiveness in reducing discomfort.

B. Having the client perform range-of-motion of the affected arm: This assessment is not specific to determining the effectiveness of cold therapy; it is more related to mobility or rehabilitation.

C. Monitoring the client's pulse rate: While pain can affect pulse rate, this is an indirect and nonspecific measure of pain or swelling reduction.

D. Inspecting the site for reduced swelling: Swelling reduction can be an indicator of decreased inflammation, but it does not provide a direct assessment of the client’s pain levels.

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Correct Answer is D

Explanation

A. "I promise I won't tell anyone about this." This is incorrect because nurses are mandated reporters and must report abuse to appropriate authorities. Promising confidentiality is misleading and violates legal obligations.

B. "Your family is bad for doing this to you." Making judgmental statements about the family can hinder the therapeutic relationship and may increase the child’s stress or feelings of loyalty conflict.

C. "Let's discuss what happened with your family here." Discussing abuse in the presence of the family may put the child at risk for retaliation and discourage open communication.

D. "It is not your fault that this happened." This statement reassures the child and helps mitigate feelings of guilt or shame that are common in abuse victims. It is supportive, nonjudgmental, and developmentally appropriate, fostering trust and safety.

A. Encourage visitors throughout the day. B. Provide the client with earplugs. C. Spread client care activities throughout the shift. D. Keep the door to the client's room open.

Correct Answer is B

Explanation

A. Encourage visitors throughout the day: Increased visitor interactions may worsen sensory overload by adding more stimuli.

B. Provide the client with earplugs. Earplugs help reduce environmental noise and sensory input, addressing the client's sensory overload and promoting rest and comfort.

C. Spread client care activities throughout the shift: Consolidating care activities, rather than spreading them out, minimizes interruptions and helps reduce sensory input.

D. Keep the door to the client's room open: Keeping the door open can increase noise and stimuli, exacerbating sensory overload.

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A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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