A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

2+ pitting edema

7.5 cm (3 in) diameter bruise on the ankle

Capillary refill 4 seconds

Warts on the affected ankle

Answer and Explanation

The Correct Answer is C

A.   2+ pitting edema is not a contraindication to cold application; in fact, cold application can help reduce edema.
B.   A 7.5 cm (3 in) diameter bruise on the ankle is not a contraindication to cold application; cold can help reduce swelling and alleviate pain.
C.   Capillary refill of 4 seconds suggests compromised blood flow, and cold application may further impair circulation. It is a contraindication.
D.   Warts on the affected ankle are not a contraindication to cold application.

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Correct Answer is A

Explanation

A) The client should hold the cane on the unaffected side to provide support for the affected side, which is weaker. Holding the cane on the affected side does not offer the necessary support and balance needed during ambulation, indicating a need for further teaching.
B) Keeping two points of support on the ground, such as one foot and the cane or both feet, is a safe practice that ensures stability while ambulating, so no further teaching is necessary for this action.
C) Advancing the cane before moving the unaffected leg is the correct technique. The cane should be moved first, followed by the affected leg, and then the unaffected leg, to maintain balance and support.
D) Supporting weight on both legs when moving the cane forward is appropriate as it provides a stable base and prevents the client from falling, indicating that the client understands the correct use of the cane.

A. "While your child is in this phase, feed him anything that he will eat." B. "Your child's change in eating habits must concern you." C. "As long as your child appears healthy, no intervention is necessary." D. "Increase the amount of calories and water your child consumes."

Correct Answer is C

Explanation

A. Encouraging feeding anything the child will eat might lead to poor nutrition. It's important to ensure a balanced diet.
B. Acknowledging the concern is valid, but the nurse should provide guidance rather than just expressing concern.
C. This response acknowledges the concern but reassures the parent that, if the child appears healthy, no immediate intervention is necessary, promoting a balanced approach.
D. Increasing calories and water without a specific reason or assessment may not address the underlying issue and is not the initial recommended intervention.

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A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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