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 D

Explanation

A) Placing one crutch on each side when assuming a sitting position is not indicative of safe crutch use as it does not provide adequate support or balance during the transition from standing to sitting.
B) Placing weight on the axillae, or underarms, can cause nerve damage due to the pressure on the radial nerve located there; therefore, this is not a safe practice.
C) When descending stairs, the affected leg should be moved first, followed by the crutches and then the unaffected leg, to maintain balance and safety. Therefore, moving the unaffected leg onto a step first is not the safest option.
D) Having slightly flexed elbows allows for proper distribution of weight and helps in maintaining balance while ambulating with crutches, making it the correct and safe method.

A. Obtain apical and radial rates simultaneously. B. Palpate pulses in the lower extremities. C. Check blood pressure in left and right arms. D. Compare the pulse strength in upper extremities.

Correct Answer is A

Explanation

A. Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a
stethoscope) is greater than the radial rate (palpated at the wrist).

B. Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output.

C. Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit.
D. Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.

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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

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