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. Autonomy: Respecting a client’s right to make their own decisions, including the refusal of a protein and calorie supplement, demonstrates the ethical principle of autonomy.

B. Fidelity: Fidelity involves being faithful to commitments and responsibilities, but this scenario focuses on the client’s decision-making rights rather than the nurse’s loyalty.

C. Veracity: Veracity refers to truth-telling, which is not directly related to the client refusing the supplement.

D. Beneficence: Beneficence involves acting in the client’s best interest, but forcing treatment would conflict with respecting autonomy.

A. Place throw rugs and carpets throughout the home to add comfort and warmth. B. Ensure that all electrical cords and wires are secured against walls and out of walkways. C. Install bright, overhead lighting in every room and hallway to improve visibility. D. Encourage the client to use a walking stick or guide dog when moving around the home. E. Label kitchen cabinets and drawers with large-print, high-contrast labels.

Correct Answer is ["B","C","D","E"]

Explanation

A. Place throw rugs and carpets throughout the home to add comfort and warmth: Throw rugs and carpets can increase the risk of falls, especially for clients with vision impairments. They should be avoided.

B. Ensure that all electrical cords and wires are secured against walls and out of walkways: Preventing tripping hazards is critical for a client with vision impairment.

C. Install bright, overhead lighting in every room and hallway to improve visibility: Adequate lighting is essential for clients with glaucoma to help them navigate safely.

D. Encourage the client to use a walking stick or guide dog when moving around the home: This enhances mobility and safety for clients with decreased vision by providing support and guidance.

E. Label kitchen cabinets and drawers with large-print, high-contrast labels: This helps the client identify items more easily and reduces the risk of injury or confusion.

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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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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?