Nokea
The nurse understands that local heat application can cause which of the following?
- A. Vasodilation
- B. Increased cellular metabolism
- C. Vasoconstriction
- D. Relaxed muscles
- E. Decreased pain
- F. Decreased blood flow to the site
Correct Answer: A,B,D,E
Rationale: Heat causes vasodilation, increases metabolism, relaxes muscles, and reduces pain by improving blood flow.
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Which of the following treatments would possibly help relieve a patient's discomfort from a muscle spasm in her lumbar area?
- A. Immersion in a whirlpool
- B. Administration of a tepid sponge bath
- C. Application of a warm pack
- D. Application of a cold pack
Correct Answer: C
Rationale: Warm packs relax muscles and increase blood flow, relieving muscle spasms.
During a cold application, which of the following assessment findings would indicate the cold pack should be removed immediately?
- A. Skin is pink.
- B. Skin is white.
- C. Skin is mottled.
- D. Patient complains of a 'burning' sensation.
- E. Skin is very cool to the touch.
- F. Patient states the itching from the rash site is decreasing.
Correct Answer: B,C,D
Rationale: White, mottled skin and a burning sensation indicate tissue damage from excessive cold, necessitating immediate removal.
During a heat application, which of the following assessment findings would indicate the heat pack should be removed immediately?
- A. Skin is pale pink.
- B. Skin is dark red.
- C. Temperature of the site is slightly warmer than surrounding skin.
- D. Patient denies discomfort.
- E. Skin is starting to look 'bubbly.'
- F. Skin is hot to the touch.
Correct Answer: B,E,F
Rationale: Dark red skin, bubbly appearance, and hot skin indicate potential burns, requiring immediate removal of the heat pack.
The nurse is preparing a sitz bath for a postpartum mother. The nurse understands the water must be hung to what level?
- A. 18 to 24 inches
- B. 15 to 20 inches
- C. 17 to 25 inches
- D. 10 to 22 inches
Correct Answer: B
Rationale: Sitz bath water is typically hung 15-20 inches above the patient to ensure proper flow and comfort.
A patient has an erythematous area at the site where you just discontinued an IV infusion. There is no edema, but the patient complains of the site being very tender. Which of the following would be the treatment of choice?
- A. Telling the patient the tenderness will subside without treatment
- B. Administering a sitz bath
- C. Applying an ice pack
- D. Applying a warm pack
Correct Answer: C
Rationale: Ice reduces inflammation and tenderness at the IV site by causing vasoconstriction.