Which of the following clients should avoid the use of cold therapy?

A 32-year-old with menstrual cramps.

A78-year-old with peripheral arterial disease.

A44 year old with a hematoma to the leg

A 69-year-old with a pulled muscle

Answer and Explanation

The Correct Answer is B

A. A 32-year-old with menstrual cramps. Cold therapy can help relieve pain and reduce pelvic inflammation.

B. A 78-year-old with peripheral arterial disease. Cold therapy causes vasoconstriction, which can further reduce circulation in clients with PAD, increasing the risk of tissue damage.

C. A 44-year-old with a hematoma to the leg: Cold therapy is recommended for hematomas as it reduces swelling and bleeding.

D. A 69-year-old with a pulled muscle: Cold therapy reduces inflammation and numbs pain, making it beneficial for muscle injuries.

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Correct Answer is C

Explanation

A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.

B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.

C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.

D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.

A. Apply restraints to the patient's wrists. B. Turn on the patient's bed alarm. C. Administer a sedating medication. D. Move the patient closer to the nurse's station.

Correct Answer is D

Explanation

A. Apply restraints to the patient's wrists. Restraints should be a last resort and only used when all other interventions have failed. Before restraining, less restrictive methods such as reorientation, supervision, and environmental modifications should be attempted first.

B. Turn on the patient’s bed alarm. While a bed alarm can alert staff if the patient attempts to get out of bed, it does not prevent the patient from pulling at their dressings and IV lines. More direct supervision is needed.

C. Administer a sedating medication. Sedation should be used cautiously, as it may increase the risk of falls, delirium, and respiratory depression. Non-pharmacologic interventions should be attempted first unless the patient is a danger to themselves or others.

D. Move the patient closer to the nurse’s station. This is the best first intervention. Placing the patient closer to the nurses' station allows for increased supervision and quicker intervention while also helping to reduce agitation through reassurance and reorientation.

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Which of the following clients should avoid the use of cold therapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

Correct Answer is C

Explanation

After hourly rounds, the primary nurse notes that the patient is agitated, continually pulling at their wound dressings and intravenous lines and has decided to notify the charge nurse. During SBAR, what intervention should the primary nurse recommend?

Correct Answer is D

Explanation

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