A nurse is teaching a client about the use of ice for treatment of a soft-tissue injury. Which of the following instructions should be included? (Select All that Apply.)

Alternate the use of ice and heat.

Apply ice pack intermittently.

Do not place ice pack directly on the skin.

Leave ice pack on for no more than 20 minutes at a time.

Answer and Explanation

The Correct Answer is B

Choice A Reason: Alternate the use of ice and heat

Alternating the use of ice and heat is not typically recommended for the initial treatment of a soft-tissue injury. Ice is generally used during the first 24-48 hours to reduce swelling and inflammation. Heat can be applied later to help relax muscles and improve blood flow, but it should not be used immediately after an injury as it can increase swelling.

Choice B Reason: Apply ice pack intermittently

Applying the ice pack intermittently is important to prevent skin damage and frostbite. It is generally recommended to apply ice for 15-20 minutes at a time, followed by a break of at least 20 minutes before reapplying. This helps to reduce swelling and pain without causing harm to the skin and underlying tissues.

Choice C Reason: Do not place ice pack directly on the skin

Placing an ice pack directly on the skin can cause frostbite and damage to the skin and tissues. It is important to wrap the ice pack in a thin cloth or towel before applying it to the injured area. This provides a barrier that protects the skin while still allowing the cold to penetrate and reduce swelling.

Choice D Reason: Leave ice pack on for no more than 20 minutes at a time

Leaving the ice pack on for no more than 20 minutes at a time is crucial to prevent frostbite and skin damage. Prolonged exposure to cold can cause harm, so it is important to limit the duration of each application and take breaks in between.

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Correct Answer is D

Explanation

Choice A Reason: The client should maintain systolic BP between 130 and 135 mm Hg

Maintaining a systolic BP between 130 and 135 mm Hg is higher than the recommended range for someone who has experienced a transient ischemic attack (TIA). According to the American Heart Association, the goal for systolic BP in patients with a history of TIA or stroke should be lower to reduce the risk of recurrent events. While this range is not extremely high, it is still above the optimal target for secondary prevention.

Choice B Reason: The client should maintain systolic BP between 141 and 145 mm Hg

This range is significantly higher than the recommended target for systolic BP in patients with hypertension and a history of TIA. Elevated BP in this range increases the risk of recurrent stroke and other cardiovascular events. Effective BP management is crucial in reducing these risks, and maintaining a systolic BP in this range would not be advisable.

Choice C Reason: The client should maintain systolic BP between 136 and 140 mm Hg

Although this range is slightly lower than choice B, it is still above the optimal target for patients with a history of TIA. Research indicates that tighter BP control can significantly reduce the risk of recurrent strokes. Therefore, maintaining a systolic BP in this range would not be ideal for secondary prevention.

Choice D Reason: The client should maintain systolic BP between 120 and 129 mm Hg

This range aligns with the current guidelines for BP management in patients with a history of TIA or stroke. Maintaining a systolic BP between 120 and 129 mm Hg helps reduce the risk of recurrent cerebrovascular events4. This target is considered optimal for secondary prevention and is supported by evidence from various studies and clinical guidelines.

A. I will call your provider so we can discuss it. B. What are you thinking that you would like to do? C. You have the right to refuse if you don’t think you can do this. D. Many clients your age are able to adjust surprisingly well to a prosthesis.

Correct Answer is D

Explanation

Choice A Reason: I will call your provider so we can discuss it

While this response shows the nurse’s willingness to involve the healthcare provider, it does not directly address the client’s concern about their ability to manage the prosthesis. It is important to provide immediate reassurance and encouragement to the client, which this response lacks.

Choice B Reason: What are you thinking that you would like to do?

This response is open-ended and encourages the client to express their feelings and thoughts. While it is a good approach to understand the client’s perspective, it does not provide the immediate reassurance and encouragement that the client needs to feel confident about managing the prosthesis.

Choice C Reason: You have the right to refuse if you don’t think you can do this

This response acknowledges the client’s autonomy but may inadvertently reinforce their doubts and fears about managing the prosthesis. It is important to encourage and support the client rather than focusing on their right to refuse.

Choice D Reason: Many clients your age are able to adjust surprisingly well to a prosthesis

This response is the most appropriate as it provides reassurance and encouragement to the client. By sharing that many clients of a similar age have successfully adjusted to a prosthesis, the nurse helps to build the client’s confidence and reduce their anxiety about managing the new situation. This positive reinforcement can be very motivating for the client.

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A nurse is teaching a client about the use of ice for treatment of a soft-tissue injury. Which of the following instructions should be included? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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