Chapter 08 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

Chapter 08 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

• The nurse applies an aquathermia heat pack to the client’s right leg and removes it after no more 1) than 45 minutes in order to avoid:

1. A) B) Rebound phenomena.
2. C) Heat D) Systemic effects.

Answer: B

Explanation: A)       A rebound phenomenon occurs at the time the maximum therapeutic effect is achieved and the opposite effects begin, and can result in a burn. Vasodilation is the desired effect of heat. Heat tolerance begins shortly after applying the heat pack as the skin adapts to the warmth. Systemic effects will occur when heat is applied to a large localized area of the body, increasing cardiac output and

pulmonary ventilation.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. A rebound phenomenon occurs at the time the maximum therapeutic effect is achieved and the opposite effects begin, and can result in a Vasodilation is the desired effect of heat. Heat tolerance begins shortly after applying the heat pack as the skin adapts to the warmth. Systemic effects will occur when heat is applied to a large localized area of the body, increasing cardiac output and

pulmonary ventilation.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. A rebound phenomenon occurs at the time the maximum therapeutic effect is achieved and the opposite effects begin, and can result in a Vasodilation is the desired effect of heat. Heat tolerance begins shortly after applying the heat pack as the skin adapts to the warmth. Systemic effects will occur when heat is applied to a large localized area of the body, increasing cardiac output and

pulmonary ventilation.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. A rebound phenomenon occurs at the time the maximum therapeutic effect is achieved and the opposite effects begin, and can result in a Vasodilation is the desired effect of heat. Heat tolerance begins shortly after applying the heat pack as the skin adapts to the warmth. Systemic effects will occur when heat is applied to a large localized area of the body, increasing cardiac output and

pulmonary ventilation.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

Objective: Learning Outcome 8-1: Define the key terms used in the skills of heat and cold measures.

 

• The client calls the nurse into the room and says that the heat pack the nurse applied feels cold, and 2) asks the nurse to turn the heat up on the aquathermia The nurse’s best response would be:

1. A) “I’ll turn it up a little at a time and you let me know when it feels warm ”
   1. “The doctor wants the aquathermia pad maintained at a specific temperature, so there’s no need to change “
   2. C) “The aquathermia pad still feels warm to “
   3. “Your body has adjusted to the warmth, and is making it feel cooler, but it’s actually the same temperature as when it was first “

Answer: D

Explanation: A)      When the heat pack is applied, the body vasodilates the vessels near the warmth and the heat pack begins to feel cold, when in fact it is the same temperature it was when first applied. If the nurse increases the temperature, there is a great risk the client will be burned. Telling the client the doctor ordered it this way or that the pad feels warm to the nurse does not explain the phenomenon that causes the pad to feel cooler or give the client a reason for why the temperature is not increased. Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. When the heat pack is applied, the body vasodilates the vessels near the warmth and the heat pack begins to feel cold, when in fact it is the same temperature it was when first If the nurse increases the temperature, there is a great risk the client will be burned. Telling the client the doctor ordered it this way or that the pad feels warm to the nurse does not explain the phenomenon that causes the pad to feel cooler or give the client a reason for why the temperature is not increased. Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. When the heat pack is applied, the body vasodilates the vessels near the warmth and the heat pack begins to feel cold, when in fact it is the same temperature it was when first If the nurse increases the temperature, there is a great risk the client will be burned. Telling the client the doctor ordered it this way or that the pad feels warm to the nurse does not explain the phenomenon that causes the pad to feel cooler or give the client a reason for why the temperature is not increased. Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. When the heat pack is applied, the body vasodilates the vessels near the warmth and the heat pack begins to feel cold, when in fact it is the same temperature it was when first If the nurse increases the temperature, there is a great risk the client will be burned. Telling the client the doctor ordered it this way or that the pad feels warm to the nurse does not explain the phenomenon that causes the pad to feel cooler or give the client a reason for why the temperature is not increased. Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

Objective: Learning Outcome 8-2: Identify essential guidelines for applying heat and cold.

• The nurse recognizes that which of the following affect the client’s physiological tolerance to heat 3) and cold? Select all that

1. Body part
2. Race and ethnic origin
3. Size of the exposed body part
4. Intactness of the skin

 

1. E) Length of exposure

Answer: A, C, D, E

Explanation: A)      Some body parts, such as the back of the hand or foot, are not

temperature-sensitive, while other areas, such as the wrist and neck, are more temperature-sensitive. The larger the area exposed to heat and cold, the lower the tolerance. People feel hot and cold application most while the temperature is changing, and then tolerance increases, so length of exposure is a factor. Injured skin, or skin that is not intact, is more temperature-sensitive. Race and ethnic background are not factors influencing temperature tolerance.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. Some body parts, such as the back of the hand or foot, are not

temperature-sensitive, while other areas, such as the wrist and neck, are more temperature-sensitive. The larger the area exposed to heat and cold, the lower the tolerance. People feel hot and cold application most while the temperature is changing, and then tolerance increases, so length of exposure is a factor. Injured skin, or skin that is not intact, is more temperature-sensitive. Race and ethnic background are not factors influencing temperature tolerance.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. Some body parts, such as the back of the hand or foot, are not

temperature-sensitive, while other areas, such as the wrist and neck, are more temperature-sensitive. The larger the area exposed to heat and cold, the lower the tolerance. People feel hot and cold application most while the temperature is changing, and then tolerance increases, so length of exposure is a factor. Injured skin, or skin that is not intact, is more temperature-sensitive. Race and ethnic background are not factors influencing temperature tolerance.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. Some body parts, such as the back of the hand or foot, are not

temperature-sensitive, while other areas, such as the wrist and neck, are more temperature-sensitive. The larger the area exposed to heat and cold, the lower the tolerance. People feel hot and cold application most while the temperature is changing, and then tolerance increases, so length of exposure is a factor. Injured skin, or skin that is not intact, is more temperature-sensitive. Race and ethnic background are not factors influencing temperature tolerance.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. Some body parts, such as the back of the hand or foot, are not

temperature-sensitive, while other areas, such as the wrist and neck, are more temperature-sensitive. The larger the area exposed to heat and cold, the lower the tolerance. People feel hot and cold application most while the temperature is changing, and then tolerance increases, so length of exposure is a factor. Injured skin, or skin that is not intact, is more temperature-sensitive. Race and ethnic background are not factors influencing temperature tolerance.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

Objective: Learning Outcome 8-2: Identify essential guidelines for applying heat and cold.

 

• The nurse receives a call from a client who reports a deep, long cut to the left hand sustained while 4) slicing a bagel and asks the nurse what to The nurse would direct the client to do which of the following?
  1. Elevate the arm above the head and apply ice and pressure while en route to the Emergency

1. Apply heat and pressure en route to the Emergency
2. Apply ice and elevate the
3. Apply pressure and elevate the

Answer: A

Explanation: A)      The nurse would advise the client to apply ice because it will cause vasoconstriction, and to elevate the arm while applying direct pressure to the wound in order to slow the bleeding process. Heat would increase blood flow to

the wound.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. The nurse would advise the client to apply ice because it will cause

vasoconstriction, and to elevate the arm while applying direct pressure to the wound in order to slow the bleeding process. Heat would increase blood flow to

the wound.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. The nurse would advise the client to apply ice because it will cause

vasoconstriction, and to elevate the arm while applying direct pressure to the wound in order to slow the bleeding process. Heat would increase blood flow to

the wound.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. The nurse would advise the client to apply ice because it will cause

vasoconstriction, and to elevate the arm while applying direct pressure to the wound in order to slow the bleeding process. Heat would increase blood flow to

the wound.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

Objective: Learning Outcome 8-3: Identify indications and contraindications for heat and cold measures.