A nurse is teaching a client how to do pursed-lip breathing.
What is the therapeutic effect of this procedure?

Choice A rationale

Safety event reports, also known as incident reports, are designed to record facts rather than subjective opinions or future recommendations. While hospitals use these reports for quality improvement and to develop prevention strategies, the individual filling out the report should focus on what actually happened. Adding suggestions within the primary report can sometimes complicate the objective nature of the legal document. Prevention analysis is usually handled by a separate risk management committee during follow-up reviews.

Choice B rationale

Discussing the report details with a confused client before documenting is often counterproductive and may lead to inaccurate information. A confused client may not have a reliable memory of the fall, and their input might be influenced by their cognitive state. The nurse's primary duty is to assess the client for injuries immediately. Once the client is safe, the nurse should document the objective findings and observed events directly, rather than waiting for a discussion with the client.

Choice C rationale

Accuracy in the medical record is essential for legal and clinical reasons after a fall. The nurse must document the objective facts of the event, including the time, the client's position when found, and any immediate physical findings or symptoms. Additionally, the nurse must record the interventions taken, such as notifying the physician and the client's subsequent response. This provides a clear timeline and evidence that the standard of care was followed to protect the client.

Choice D rationale

Providing minimal information is a poor practice that can lead to missing critical data needed for root cause analysis. A safety report must be thorough and include all relevant environmental factors, such as whether the bed rails were up or if the floor was wet. Omitting details can mask patterns that contribute to falls across a unit. Comprehensive reporting is the only way to ensure that healthcare systems can learn from errors and improve patient safety outcomes.

Choice A rationale

Cold therapy induces local vasoconstriction, which reduces the diameter of blood vessels and decreases capillary permeability. This physiological response limits the leakage of fluid into the interstitial spaces, thereby minimizing edema and swelling at the injury site. Furthermore, the reduction in blood flow slows the inflammatory cascade and decreases the release of chemical mediators like histamine and bradykinin, which effectively reduces redness and provides an analgesic effect by numbing local nerve endings.

Choice B rationale

Cold application typically functions as a local anesthetic by slowing the conduction velocity of sensory nerve fibers. While the initial application of an ice pack might feel uncomfortably cold or produce a stinging sensation, the ultimate goal and expected outcome of cryotherapy is a significant reduction in pain. Increased discomfort would suggest a potential complication, such as cold-induced tissue damage or frostbite, rather than the intended therapeutic effect of soothing the injured area.

Choice C rationale

Cold therapy is designed to decrease vascularity and promote fluid retention within the vessels through constriction. An increase in serous drainage would imply an increase in capillary leakage or inflammatory exudate, which contradicts the intended physiological outcome of ice application. By stabilizing cell membranes and reducing hydrostatic pressure in the capillaries, cold therapy should lead to a drier wound environment and a decrease in the volume of drainage from a surgical incision.

Choice D rationale

Because cold causes the smooth muscles in the walls of the arterioles to contract, the resulting vasoconstriction actually helps to control minor bleeding rather than increasing it. Heat therapy would cause vasodilation and potentially increase bleeding, but cold is a standard intervention for promoting hemostasis. Any observation of increased bleeding following the application of ice would be an abnormal finding and could indicate that the cold has caused skin shivering or other unintended systemic reactions.