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. Tilted head forward is not necessary during inhaler use. The client should maintain an upright position.
B. Shaking the inhaler before use is correct to ensure proper dispersion of the medication.
C. Rinsing the mouth out before using the inhaler is not necessary for proper technique.
D. Waiting 10 seconds between puffs allows for optimal delivery of the medication to the airways.

A. Unsteady gait B. Report of short-term memory loss C. Hearing loss D. Report of frequent constipation

Correct Answer is A

Explanation

A. An unsteady gait increases the risk of falls, which can lead to serious injuries in older adults.

A. Ensuring safety and preventing falls is a priority.

B. Short-term memory loss is common in older adults, but it may not pose an immediate risk to safety.
C. Hearing loss, while important, may not be an immediate safety concern unless it significantly impacts the individual's ability to communicate or hear warnings.
D. Frequent constipation is a common concern in older adults but may not pose an immediate threat to safety. Falls prevention takes precedence in this scenario.

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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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