Tony, a basketball player, twists his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective?

Correct Answer: C

Rationale: The correct answer is option C: "My ankle looks less swollen now." This statement suggests that the ice application has been effective in reducing swelling, which is one of the primary goals of applying ice to an acute injury like an ankle sprain. Swelling is caused by increased blood flow to the injured area, and ice helps to constrict blood vessels and reduce this inflammation. Option A, "My ankle appears redder now," is incorrect because increased redness would indicate increased blood flow and potentially worsening inflammation, which is not the desired outcome of ice application. Option B, "I need something stronger for pain relief," is incorrect because ice is commonly used as a first-line treatment for pain and inflammation in acute injuries. Seeking stronger pain relief may not be necessary if the ice application effectively reduces swelling and pain. Option D, "My ankle feels warm," is incorrect because ice typically causes a sensation of coldness, not warmth. Feeling warmth could indicate that the ice application was not effective in reducing inflammation and may not be the desired outcome. In an educational context, this question assesses the student's understanding of the rationale behind using ice for acute injuries like ankle sprains. It reinforces the importance of assessing the effectiveness of interventions based on expected outcomes such as reduced swelling in this case. Understanding these principles is crucial for nurses in providing evidence-based care and promoting optimal recovery for patients with musculoskeletal injuries.

Correct Answer: D

Rationale: The correct answer is D) There is a risk of difficulty in ending the relationship. In the termination phase of the therapeutic interpersonal process according to Hildegard Peplau, this phase involves the conclusion of the nurse-patient relationship. This phase can be challenging as both individuals may have developed a strong bond and dependency on each other throughout the therapeutic process. Ending the relationship can lead to feelings of loss, abandonment, and separation anxiety for both the nurse and the patient. Option A) A therapeutic exchange occurs is incorrect because the therapeutic exchange ideally occurs throughout all phases of the therapeutic process, not just in the termination phase. Option B) There is reserved interaction is incorrect as the termination phase is not characterized by reserved interaction but rather by addressing the emotional aspects of ending the therapeutic relationship. Option C) The nurse and patient must work interdependently is not the defining feature of the termination phase. While interdependence may have been present in earlier phases, the termination phase is more about closure and transitioning out of the therapeutic relationship. Educationally, understanding the dynamics of the termination phase in therapeutic relationships is crucial for nursing students. It prepares them to navigate the complexities of ending relationships with patients in a way that is emotionally sensitive and professionally appropriate. It also highlights the importance of acknowledgment and processing of feelings that may arise during this phase for both the nurse and the patient.

Correct Answer: A

Rationale: The correct answer is A) Assault. In nursing practice, assault refers to the act of intentionally threatening or causing fear of harmful or offensive contact with a patient. In this scenario, the nurse's threat to inject the client if they refuse to take an oral medication constitutes assault because it involves the intentional creation of fear of harm to coerce compliance. This behavior is a violation of the patient's autonomy and right to make informed decisions about their care. Option B) Battery is incorrect because battery involves the actual harmful or offensive contact without consent, not just the threat of it. In this case, the nurse has not yet performed the act but has only made a threat. Option C) Negligence is incorrect as negligence refers to a failure to provide the standard of care expected in a given situation. While the nurse's behavior is certainly inappropriate and unprofessional, it does not align with the definition of negligence. Option D) Invasion of privacy is also incorrect as this concept pertains to the unauthorized intrusion into a patient's private affairs or the disclosure of confidential information without consent, which is not the issue presented in the scenario. In an educational context, understanding legal and ethical principles in nursing practice is crucial for ensuring patient safety, promoting autonomy, and maintaining professional standards. Nurses must respect patients' rights, provide care with integrity, and always obtain informed consent before any treatment or procedure. This question highlights the importance of clear communication, respect for patient autonomy, and the consequences of inappropriate behavior in healthcare settings.

Correct Answer: C

Rationale: The correct answer is option C: Spread his or her feet apart. When assisting a client to get up in a chair, using a wide base of support by spreading the feet apart provides the nurse with better stability and balance. This wider base of support helps distribute the weight more evenly, reducing the risk of injury to both the client and the nurse. Option A is incorrect because bending at the waist can strain the nurse's back and is not a safe body mechanics practice. Option B is incorrect because placing hands on the client's forearm does not provide a wide base of support and may lead to instability during the transfer. Option D is incorrect as tightening pelvic muscles does not contribute to providing a stable base of support for the transfer. In the context of nursing, proper body mechanics are crucial to prevent musculoskeletal injuries for both the nurse and the client. Using a wide base of support is a fundamental principle in safe patient handling techniques, ensuring the transfer is conducted safely and effectively. Mastering these techniques is essential for nurses to provide quality care while safeguarding their own health and well-being.

Correct Answer: A

Rationale: In the context of nursing delegation, the correct answer is A) Bathe a client who had an amputation 2 days ago. This task can be safely delegated to assistive personnel (AP) as it involves providing basic hygiene care and does not require specialized nursing knowledge or assessment skills. Delegating this task allows the nurse to focus on more complex aspects of patient care. Option B) Assist a client to ambulate using a gait belt involves assessing the client's mobility and gait pattern, which requires nursing judgment and assessment skills. It should not be delegated to AP as it involves a higher level of clinical decision-making. Option C) Feed a client who had a stroke 3 months ago may involve assessing swallowing ability, risk of aspiration, and monitoring for signs of dysphagia. This task requires nursing assessment and intervention based on the client's individual condition, making it inappropriate to delegate to AP. Option D) Reviewing a low-sodium diet for a client with hypertension involves providing education on dietary modifications based on the client's medical history and lab values. This task requires nursing knowledge to assess the client's specific needs and tailor the diet plan accordingly, making it unsuitable for delegation to AP. In an educational context, understanding the principles of delegation is crucial for nursing students to provide safe and effective patient care. Nurses must be able to differentiate tasks that can be delegated from those that require nursing assessment and intervention. Developing critical thinking skills in delegation ensures that patient safety and quality of care are maintained.