A nurse is caring for a client who is newly diagnosed with Parkinson’s disease. The client states, “I have no idea why I got this.” Which of the following is the most important question the nurse should ask this client while performing the assessment?

Choice A Reason:

Removing the protective gown before removing gloves is incorrect. The correct procedure is to remove gloves first, followed by the gown, to prevent contamination from the gown to the hands.

Choice B Reason:

Using an electronic thermometer is not recommended for clients with Clostridium difficile. Disposable thermometers or dedicated equipment should be used to prevent cross-contamination.

Choice C Reason:

This is the correct answer. The protective gown should be removed before leaving the client’s room to prevent the spread of Clostridium difficile spores to other areas of the healthcare facility. Proper removal and disposal of PPE are crucial in infection control.

Choice D Reason:

Shaking bed linens is incorrect as it can aerosolize Clostridium difficile spores, increasing the risk of spreading the infection. Linens should be carefully handled and placed in a linen bag without shaking.

Choice A Reason: Alternate the use of ice and heat

Alternating the use of ice and heat is not typically recommended for the initial treatment of a soft-tissue injury. Ice is generally used during the first 24-48 hours to reduce swelling and inflammation. Heat can be applied later to help relax muscles and improve blood flow, but it should not be used immediately after an injury as it can increase swelling.

Choice B Reason: Apply ice pack intermittently

Applying the ice pack intermittently is important to prevent skin damage and frostbite. It is generally recommended to apply ice for 15-20 minutes at a time, followed by a break of at least 20 minutes before reapplying. This helps to reduce swelling and pain without causing harm to the skin and underlying tissues.

Choice C Reason: Do not place ice pack directly on the skin

Placing an ice pack directly on the skin can cause frostbite and damage to the skin and tissues. It is important to wrap the ice pack in a thin cloth or towel before applying it to the injured area. This provides a barrier that protects the skin while still allowing the cold to penetrate and reduce swelling.

Choice D Reason: Leave ice pack on for no more than 20 minutes at a time

Leaving the ice pack on for no more than 20 minutes at a time is crucial to prevent frostbite and skin damage. Prolonged exposure to cold can cause harm, so it is important to limit the duration of each application and take breaks in between.