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
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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Related Questions
Correct Answer is D
Explanation
A. While some clients may be receptive to a scientific perspective, cultural beliefs and practices can significantly influence health-related decisions and behaviors.
B. Assigning clients to specific cultural categories can lead to stereotyping and may not account for the individual variations within a cultural group.
C. Disease and illness can indeed be influenced by cultural factors, including beliefs about health and healing practices.
D. The meaning of behavior can vary widely across cultures, and understanding the cultural context is crucial for providing culturally competent care.
Correct Answer is B
Explanation
A. Palpating the abdomen may exacerbate pain or cause discomfort, and it is not the first action in the assessment of a client with suspected appendicitis. Auscultating bowel sounds is a more appropriate initial step.
B. Auscultating bowel sounds is the priority to assess for signs of bowel obstruction or ileus, which can contribute to the client's symptoms.
C. Offering pain medication can be addressed after the initial assessment and determination of the cause of the symptoms.
D. Administering an antibiotic is premature before a diagnosis is confirmed. The priority is to assess and gather information first.
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