A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

2+ pitting edema

7.5 cm (3 in) diameter bruise on the ankle

Capillary refill 4 seconds

Warts on the affected ankle

Answer and Explanation

The Correct Answer is C

A.   2+ pitting edema is not a contraindication to cold application; in fact, cold application can help reduce edema.
B.   A 7.5 cm (3 in) diameter bruise on the ankle is not a contraindication to cold application; cold can help reduce swelling and alleviate pain.
C.   Capillary refill of 4 seconds suggests compromised blood flow, and cold application may further impair circulation. It is a contraindication.
D.   Warts on the affected ankle are not a contraindication to cold application.

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Correct Answer is D

Explanation

A. A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B. A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C. A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D. A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.

A. Date of birth B. Diagnosis C. Identification number D. Name E. Room Number

Correct Answer is ["A","C","D"]

Explanation

A. Date of birth is a commonly used identifier to confirm the client's identity.

B. Diagnosis is not an appropriate identifiers for confirming a client's identity.

C. Identification number is a unique identifier assigned to each client, helping ensure accurate identification.
D. Name is a fundamental identifier and should be used in combination with other identifiers to verify the client's identity.
E. Room number is not an appropriate identifiers for confirming a client's identity.

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A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

Nursing Test Bank

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