A nurse is developing a plan of care for a client who has cellulitis of the leg.
Which of the following interventions should the nurse include in the plan?
Elevate the affected leg on two pillows.
Apply fresh ice packs every 4 hours.
Enforce strict bedrest for 3 days.
Apply antibiotic ointment to the wound with dressing changes.
The Correct Answer is A
Choice A rationale
Elevating the affected leg promotes venous return and lymphatic drainage, which helps to reduce swelling and inflammation associated with cellulitis. Gravity assists in the removal of excess fluid from the interstitial spaces, thereby alleviating pressure and promoting healing.
Choice B rationale
Applying fresh ice packs every 4 hours can provide some pain relief and vasoconstriction, potentially reducing inflammation in the initial stages of cellulitis. However, heat is generally preferred after the acute inflammatory phase to promote circulation and healing. Frequent, prolonged ice application might impede blood flow.
Choice C rationale
While rest is important for healing, enforcing strict bedrest for 3 days might not be necessary and could increase the risk of complications such as deep vein thrombosis. Moderate activity with elevation is usually recommended to promote circulation without exacerbating the infection.
Choice D rationale
Cellulitis is a deep infection of the skin and subcutaneous tissues, typically caused by bacteria entering through a break in the skin. Applying topical antibiotic ointment is unlikely to reach the deeper infected tissues and is not the primary treatment. Systemic antibiotics are required to treat cellulitis effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Discussing the client's anxiety only after obtaining consent dismisses their current emotional state and fails to address their immediate concerns about pain. Addressing anxiety proactively fosters trust and ensures the client feels heard and supported before proceeding with the procedure. Delaying the conversation can increase the client's anxiety levels.
Choice B rationale
While the provider may administer a sedative, this statement doesn't fully address the client's anxiety about potential pain. It provides information about medication but doesn't offer reassurance or acknowledge the client's feelings. A more comprehensive approach would involve both medication and supportive communication.
Choice C rationale
Minimizing the client's anxiety by comparing it to the bowel preparation can be dismissive and doesn't validate their feelings about the procedure itself. Each individual experiences procedures differently, and focusing on the discomfort of the preparation might not alleviate their fear of pain during the colonoscopy.
Choice D rationale
Acknowledging the client's anxiety validates their feelings and establishes a supportive nurse-client relationship. Reassuring the client that measures will be taken to ensure their comfort directly addresses their concern about pain. This approach promotes trust and can help reduce the client's anxiety about the procedure.
Correct Answer is A
Explanation
Choice A rationale
Glaucoma is characterized by damage to the optic nerve, often due to increased intraocular pressure. Without proper management to lower this pressure, the damage to the optic nerve progresses, leading to irreversible vision loss and eventually blindness.
Choice B rationale
The primary goal of glaucoma treatment with eye drops is to lower intraocular pressure and prevent further damage to the optic nerve, thereby preserving existing vision. Eye drops do not typically improve vision that has already been lost due to glaucoma.
Choice C rationale
Glaucoma is usually associated with impaired drainage or overproduction of aqueous humor, leading to increased intraocular pressure, not inadequate production of fluid. This elevated pressure is the primary risk factor for optic nerve damage.
Choice D rationale
Double vision (diplopia) is not a common or characteristic symptom of glaucoma. While various eye conditions can cause double vision, glaucoma primarily affects peripheral vision and visual acuity without causing diplopia. .
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