A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
"I'll keep a heating pad on the calf of my right leg when I am lying down."
"I'll wrap a warm, wet towel around my right calf every 4 hours."
"I'll place my leg under a heat lamp every 3 hours."
"I will sit on the side of the tub and soak my right leg two times every day."
The Correct Answer is B
Rationale:
A. Keeping a heating pad on the leg for extended periods can lead to burns or skin damage. Heat therapy should be applied intermittently with breaks to prevent overheating.
B. Wrapping a warm, wet towel and applying it intermittently is appropriate for localized heat therapy and can help reduce inflammation and promote healing.
C. Using a heat lamp may not provide consistent or controlled heat application and is not the standard approach for treating cellulitis.
D. Soaking the leg in a tub is not recommended as it may introduce bacteria and potentially worsen the infection.
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Correct Answer is A
Explanation
Rationale:
A. The primary criterion for removing restraints is that the client must be calm and cooperative, indicating that the immediate safety concern has been addressed.
B. Verbalizing remorse is not a requirement for removing restraints; the focus is on the client's behavior and cooperation.
C. The provider does not need to be present for the nurse to assess the client's readiness for removal of restraints, although provider orders and assessments are important.
D. Simply verbalizing anger does not indicate that the restraints can be removed; the client must demonstrate appropriate behavior and cooperation.
Correct Answer is C
Explanation
Rationale:
A. This statement reflects a healthy boundary-setting behavior, where the client recognizes their limits and makes decisions accordingly.
B. This reflects a healthy coping mechanism, where the client acknowledges their stress and takes time to recharge, which is important for mental health.
C. This statement indicates a possible depressive symptom, as feeling hopeless and withdrawing from activities (like staying in bed and crying) can be signs of depression. This requires follow-up to assess the client's mental health and provide appropriate support.
D. Taking a walk during stressful times is a positive coping strategy that helps manage stress and maintain mental health.