A client asks a nurse how long a heat application should be left in place. Which response should the nurse make?

“Maximum benefits occur within the first five minutes.”.

“Therapeutic heat effects occur within 20 to 30 minutes.”.

“The heat should be left in place for at least one hour to be effective.”.

“Heat can be left in place for as long as 12 hours without harmful effects.”.

Answer and Explanation

The Correct Answer is B

Heat application increases blood flow and reduces muscle spasms, which can help relieve pain and promote healing. However, heat should not be applied for longer than 30 minutes at a time, as it can cause tissue damage and inflammation.

Choice A is wrong because maximum benefits do not occur within the first five minutes.

It takes time for heat to penetrate the tissues and cause vasodilation.

Choice C is wrong because the heat should not be left in place for at least one hour to be effective.

This can lead to burns, increased edema, and decreased blood flow.

Choice D is wrong because heat can not be left in place for as long as 12 hours without harmful effects.

This can cause severe tissue damage, infection, and necrosis.

Normal ranges for heat application are between 104°F and 113°F (40°C and 45°C).

The temperature should be checked frequently and adjusted according to the patient’s comfort and tolerance.

The skin should also be inspected for signs of erythema, blisters, or burns.

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Correct Answer is C

Explanation

This is because responding inappropriately to questions can indicate that the client has difficulty hearing or understanding what is being asked. According to, hearing loss makes communication with the outside world difficult, and can result in new or exaggerated symptoms that are mistakenly attributed to cognitive decline.

Choice A is wrong because speaking in a low voice does not necessarily imply hearing loss. It could be due to other factors such as shyness, anxiety, or vocal cord problems.

Choice B is wrong because refusing to answer questions does not necessarily imply hearing loss.

It could be due to other factors such as lack of interest, defiance, or distrust.

Choice D is wrong because looking away from persons while speaking does not necessarily imply hearing loss.

It could be due to other factors such as cultural norms, eye contact avoidance, or distraction.

A. Palpation, relationship, inspection, and evaluation. B. Inspection, palpation, percussion, and auscultation. C. Vital signs, health history, general survey, and height and weight. D. Auscultation, general survey, vital signs, and color.

Correct Answer is B

Explanation

Inspection, palpation, percussion, and auscultation are the four techniques used to perform a physical assessment.

Inspection involves observing the patient’s appearance, posture, movement, and behavior. Palpation involves feeling the patient’s skin, organs and pulses with the hands.

Percussion involves tapping the patient’s body with the fingers or a small hammer to elicit sounds or vibrations.

Auscultation involves listening to the patient’s heart, lungs, and bowel sounds with a stethoscope.

Choice A is wrong because relationship and evaluation are not techniques of physical assessment.

Relationship refers to the rapport and trust established between the nurse and the patient.

Evaluation refers to the process of comparing the expected outcomes with the actual outcomes of the nursing interventions.

Choice C is wrong because vital signs, health history, general survey, and height and weight are not techniques of physical assessment.

They are components of a health assessment, which is a broader term that includes physical assessment as well as other aspects of the patient’s health status.

Choice D is wrong because color is not a technique of physical assessment.

Color is an aspect of inspection, which is one of the techniques of physical assessment.

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A client asks a nurse how long a heat application should be left in place. Which response should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client behavior is indicative of hearing loss?

Correct Answer is C

Explanation

The nurse is preparing to perform a physical assessment. What are the four techniques used?

Correct Answer is B

Explanation

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