The nurse teaches a client about the effects of cold therapy on an injury.
Which statement by the client indicates that the teaching has been effective?
Redness and swelling should decrease after cold treatment.
There will be significantly more discomfort in the area where the cold is applied.
I should expect more serous drainage from the incision after the ice has been in place.
My incision may bleed more when the ice is first applied.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Washing hands for sixty seconds is generally reserved for surgical scrubbing or situations involving high-level contamination with specific pathogens. For routine hand hygiene when hands are not visibly soiled, such a long duration is unnecessary and can lead to skin irritation or breakdown. Prolonged exposure to water and soap strips natural oils from the skin, compromising the epidermal barrier, which is the body's first line of defense against infection.
Choice B rationale
The Centers for Disease Control and Prevention and World Health Organization recommend scrubbing hands for at least 20 seconds to effectively mechanical remove transient microorganisms. This duration allows sufficient time for surfactants in soap to emulsify fats and proteins found in microbial membranes, facilitating their detachment from the skin surface. Proper friction during these 20 seconds ensures that all surfaces, including interdigital spaces and subungual areas, are adequately decontaminated to prevent cross-transmission.
Choice C rationale
A 45 second scrub exceeds the standard clinical recommendation for non-surgical hand hygiene. While longer scrubbing is not harmful in terms of cleanliness, it does not provide a significantly higher reduction in transient flora compared to a 20 second scrub for non-soiled hands. In a fast-paced clinical environment, adherence to hand hygiene protocols is higher when the required time is realistic and based on the minimum effective duration needed to break the chain of infection.
Choice D rationale
Scrubbing for two minutes is far beyond the requirement for standard hand hygiene and is typically associated with pre-operative surgical hand preparation using antiseptic agents. Requiring a two minute wash for every patient encounter would be impractical for healthcare workers and would likely result in significant skin damage over time. Dermatitis caused by over-washing can actually harbor more bacteria, increasing the risk of healthcare-associated infections rather than decreasing them in the clinical setting.
Correct Answer is D
Explanation
Choice A rationale
Pain management is often secondary to physiological stabilization in respiratory care. While relaxation techniques might indirectly decrease the subjective perception of discomfort, pursed-lip breathing is specifically designed to address ventilation mechanics rather than pharmacological needs. Reducing PRN medications depends on addressing the underlying source of pain, whereas this breathing technique focuses on the alveolar pressure and air trapping associated with obstructive pulmonary conditions rather than analgesia.
Choice B rationale
Effective breathing techniques actually aim to reduce the reliance on accessory chest muscles rather than increasing their use. Overuse of intercostal and scalene muscles often indicates respiratory distress and increased work of breathing. The goal of pursed-lip breathing is to promote diaphragmatic efficiency and decrease the strain on the upper chest musculature. Increasing chest muscle use would be counterproductive and lead to faster patient fatigue and respiratory exhaustion.
Choice C rationale
An incentive spirometer is primarily used to encourage deep inspiration and prevent atelectasis by opening collapsed alveoli, particularly after surgery. Pursed-lip breathing focuses on the expiratory phase of the respiratory cycle. These two interventions serve different physiological purposes and are often used together rather than one replacing the other. Spirometry focuses on inhalation volume, while pursed-lip breathing focuses on maintaining airway patency during the exhalation process.
Choice D rationale
This technique creates positive end-expiratory pressure by providing resistance at the lips. This pressure is transmitted back through the airways, preventing them from collapsing during exhalation. By prolonging the expiratory phase, it allows for more complete emptying of the lungs and reduces the amount of trapped air. This is especially vital for clients with chronic obstructive pulmonary disease to improve gas exchange and decrease the sensation of dyspnea during physical exertion.
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