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 ["B","C","E"]
Explanation
Rationale:
A. Nylon socks are generally not considered a risk for self-harm and can be safely kept with the client.
B. A glass-framed picture presents a risk as the glass could be broken and used for self-harm. This item should be taken home.
C. Lace-up tennis shoes have long laces that could be used for self-harm, making them unsafe for a client at risk of suicide.
D. Cotton underwear does not pose a significant risk for self-harm and can be kept with the client.
E. A necklace could be used for self-harm, such as strangulation, and should be taken home to ensure the client's safety.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Increased respiratory rate is a common finding in fluid overload due to pulmonary congestion and edema, which can affect breathing.
B. Increased temperature is not directly associated with fluid overload; it is more indicative of an infection or inflammatory process.
C. Increased heart rate can occur as the heart compensates for the increased blood volume and stress on the cardiovascular system.
D. Increased blood pressure is a typical response to fluid overload due to the higher volume of circulating blood.
E. Increased hematocrit is usually not associated with fluid overload; instead, it is often increased in conditions of dehydration or hemoconcentration.