A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

Asking the client to rate the pain

Having the client perform range-of-motion of the affected arm

Monitoring the client's pulse rate

Inspecting the site for reduced swelling

Answer and Explanation

The Correct Answer is A

A. Asking the client to rate the pain: Pain rating provides a subjective measure of the intervention’s effectiveness in reducing discomfort.

B. Having the client perform range-of-motion of the affected arm: This assessment is not specific to determining the effectiveness of cold therapy; it is more related to mobility or rehabilitation.

C. Monitoring the client's pulse rate: While pain can affect pulse rate, this is an indirect and nonspecific measure of pain or swelling reduction.

D. Inspecting the site for reduced swelling: Swelling reduction can be an indicator of decreased inflammation, but it does not provide a direct assessment of the client’s pain levels.

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Correct Answer is A

Explanation

A. Level of sedation. Assessing sedation is the priority because excessive sedation could indicate opioid toxicity, which may precede respiratory depression.

B. Pain level. While assessing pain is essential, it is not the priority when evaluating the safety of opioid administration.

C. Pulse oximetry. Monitoring oxygenation is critical but follows the assessment of sedation, which directly relates to the risk of respiratory depression.

D. Blood pressure. Blood pressure monitoring is important but not as immediate a concern as sedation and respiratory function.

A. "I will only take my medications when I remember, as long as I don't have any symptoms." B. "I will avoid discussing my symptoms with my healthcare provider unless they become severe." C. "I will follow the treatment plan exactly as prescribed, even if I start to feel better before the treatment is complete." D. "I will seek immediate medical attention for any new or worsening symptoms, even if they seem minor."

Correct Answer is C

Explanation

A. "I will only take my medications when I remember, as long as I don't have any symptoms.": Inconsistent medication adherence, especially for chronic conditions, can lead to poor control and complications.

B. "I will avoid discussing my symptoms with my healthcare provider unless they become severe.": Early reporting of symptoms is critical for timely intervention and adjustment of the treatment plan.

C. "I will follow the treatment plan exactly as prescribed, even if I start to feel better before the treatment is complete." Adherence to the prescribed treatment plan ensures effective management of chronic conditions and prevents complications or relapse. Stopping treatment prematurely, even when symptoms improve, can lead to worsening conditions or incomplete recovery.

D. "I will seek immediate medical attention for any new or worsening symptoms, even if they seem minor.": While seeking attention for worsening symptoms is important, interpreting all minor changes as emergencies may lead to unnecessary healthcare utilization.

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A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

Nursing Test Bank

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