When caring for a client who is receiving a warm, moist compress to relieve lower back pain, which of the following findings should indicate to the nurse that the compress has been effective?
The client's skin on the lower back is intact without redness.
The client states that he is able to concentrate while reading.
The client's vital signs are within the expected reference range.
The client is laughing at a television show.
The Correct Answer is A
This indicates that the compress has been effective in relieving lower back pain and has not caused any skin irritation or damage.
Choice B is wrong because the ability to concentrate while reading is not directly related to the effectiveness of a warm, moist compress for relieving lower back pain.
Choice C is wrong because vital signs being within the expected reference range does not necessarily indicate that the compress has been effective in relieving lower back pain.
Choice D is wrong because laughing at a television show does not necessarily indicate that the compress has been effective in relieving lower back pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The priority intervention for a client with a new diagnosis of terminal cancer is to discuss the client’s prior coping mechanisms.
This can help the nurse understand how the client has dealt with difficult situations in the past and can provide insight into how the client may cope with their current diagnosis.
Choice B is wrong because while teaching the client to use progressive relaxation techniques may be helpful in managing stress and anxiety, it is not the priority intervention.
Choice C is wrong because while helping the client find a local support group may provide emotional support, it is not the priority intervention.
Choice D is wrong because while developing a list of goals with the client may provide direction and focus, it is not the priority intervention.
Correct Answer is C
Explanation
The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
“The higher the score, the higher the pressure injury risk”: This statement is incorrect.
The lower the score on the Braden scale, the higher the risk for pressure injury.
“Each element has a range from one to five points”: This statement is incorrect.
Each element has a range from one to four points, except for friction/shear which has a range from one to three points.
“The client’s age is part of the measurement”: This statement is incorrect. Age is not one of the elements measured by the Braden scale.
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