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 C

Explanation

A. Encouraging client feedback about satisfaction with the facility experience: This reflects client-centered care but does not directly demonstrate autonomy.

B. Explaining unit rules and policies regarding unacceptable behaviors: This action involves setting expectations rather than promoting client autonomy.

C. Supporting the client's wish to refuse prescribed medications. Autonomy involves respecting a client's right to make their own decisions about their care, including the decision to refuse treatment, as long as they have the capacity to do so.

D. Making sure the client understands expectations for client participation: This is about ensuring clarity of expectations rather than honoring the client's right to self-determination.

A. Instruct the family about anticipatory grieving B. Explore effective ways of family coping C. Encourage the family’s expression of their feelings D. Discuss the disease and its manifestations with family members

Correct Answer is C

Explanation

A. Instruct the family about anticipatory grieving: While anticipatory grieving is important, it is better addressed after the family has had time to express initial feelings.

B. Explore effective ways of family coping: This is important but should come after encouraging the family to process their immediate feelings.

C. Encourage the family’s expression of their feelings. The first priority is to allow the family to express their emotions and begin the grieving process. Encouraging emotional expression helps the family cope with the overwhelming news and facilitates their emotional support needs.

D. Discuss the disease and its manifestations with family members: While understanding the disease is essential, focusing on the family's emotional response is more critical at this initial stage of shock and grief.

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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?

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