The nurse enters the room of a client with a Clostridium difficile infection to administer an IV antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning the client’s buttocks and reports the client has been incontinent with diarrhea. The UAP is wearing gloves but not a gown. Which action should the nurse implement first?

Choice A reason: The rebound phenomenon, related to cerebellar function, is irrelevant to heating pad application. Heat therapy requires assessing skin sensation to prevent burns. Neurosensory impairment increases burn risk, making sensory assessment critical. Checking for rebound phenomenon does not address the immediate safety concerns of heat application.

Choice B reason: Muscle strength and tone inform mobility or rehabilitation but are not primary concerns for heating pad use. Impaired sensation heightens burn risk, as clients may not feel excessive heat. Sensory assessment takes precedence to ensure safe application, as muscle status does not directly impact heat therapy safety.

Choice C reason: Limitations to range of motion are relevant for mobility but not critical for heating pad safety. Neurosensory impairment increases the risk of burns, as clients may not detect overheating. Sensory assessment ensures the client can report discomfort, making it the priority over joint mobility before applying heat.

Choice D reason: Assessing neurosensory impairment is critical before applying a heating pad, as impaired sensation increases burn risk. Clients with neuropathy or reduced sensation may not feel excessive heat, leading to tissue damage. This assessment ensures safe application, aligning with nursing safety protocols to prevent thermal injury during heat therapy.

Choice A reason: Newly pregnant women benefit from informational teaching about prenatal care, but role-playing is less effective for this group. Their focus is on factual knowledge, like nutrition or labor preparation. Role-playing is better suited for behavioral change, making it less impactful for this group’s educational needs.

Choice B reason: Older adults preparing for retirement need guidance on financial or lifestyle adjustments, where role-playing is less effective. Didactic or discussion-based teaching better addresses their needs. Role-playing suits behavioral skill-building, which is not the primary focus for this group, making it a less beneficial method.

Choice C reason: Adolescents learning to abstain from drugs benefit from role-playing, as it builds skills to resist peer pressure and practice refusal strategies. This interactive method engages teens, reinforcing behavioral change through simulated scenarios. Evidence supports role-playing for adolescent substance abuse prevention, making it highly effective for this group’s needs.

Choice D reason: Men admitting a drinking problem benefit from support groups or counseling, but role-playing is less tailored to their needs. Their focus is on emotional processing and coping strategies. Role-playing is more effective for skill-building in social contexts, like drug refusal, than for addressing established addiction.