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 D

Explanation

A. Green, soft stool after the patient received antibiotics: Green stool can be a side effect of antibiotics due to changes in gut flora but is not typically concerning.

B. Large, loose stool after the patient received a laxative: This is an expected outcome of laxative use and is not cause for concern.

C. Dry, hard stool from a patient receiving opiates: Opiates commonly cause constipation. While this requires management, it is not the most concerning finding.

D. Black tarry stool from a patient receiving an anticoagulant: Black tarry stool (melena) indicates gastrointestinal bleeding, which can be life-threatening, especially in a patient on anticoagulants. Immediate assessment is required.

A. Palpate for pedal pulses. B. Turn the patient every three hours. C. Document the stage 1 pressure injury. D. Elevate bilateral heels.

Correct Answer is A

Explanation

A. Palpate for pedal pulses: Cool skin may indicate poor circulation or ischemia. Checking pedal pulses helps assess blood flow. This step provides essential information about the vascular status of the patient's foot, guiding further interventions.

B. Turn the patient every three hours: Patients on bedrest should be turned every 2 hours, not every 3 hours, to prevent pressure injuries.

C. Document the stage 1 pressure injury: Blistering indicates at least a Stage 2 pressure injury, not Stage 1. The nurse must assess further before staging.

D. Elevate bilateral heels: Once assessment confirms the need, elevating the heels can help reduce pressure and promote circulation, potentially preventing further damage and aiding in the healing process.

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

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Naxlex Comprehensive Predictor Exams

The nurse is assessing the patient's output for the shift. What finding is most concerning?

Correct Answer is D

Explanation

While bathing a patient who is on bedrest, the nurse notes an area of blistering and hypopigmentation on the patient's right heel. Upon further assessment, the area is also tender and cooler than the surrounding area. What is the next best action by the nurse?

Correct Answer is A

Explanation

A patient lives in a rural area and requires frequent appointments related to their health condition. Which of the following interventions should the nurse facilitate?

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