Question 1

The nursing assistant administers a back massage to a client and observes a reddened area in the lower back. What is the appropriate action for the nursing assistant to take?

Accepted Answer

Avoiding the reddened area while massaging the rest of the back will improve circulation to the healthy tissue and help the resident to relax. Rubbing the reddened area would increase damage to the skin. Chilling the lotion and dabbing it onto the area would be uncomfortable for the person and not serve any purpose. Charting the observation and failing to report it will allow the skin breakdown to continue without treatment.

Question 2

Which statement(s) about pain is accurate? Select all that apply.

Accepted Answer

While pain is the body's distress signal, it is a very individualized sensation and is not felt the same by all people. Pain does tell us that we have been injured, that we have overworked a muscle group, that an organ is not working properly, or that we are ill.

Question 3

What can a nursing assistant do to help a resident cope with knee pain without first asking the nurse?

Accepted Answer

The radio program may distract the resident from the pain. Applying heat to the resident's knee or administering pain medication is not within a nursing assistant's scope of practice. Range-of-motion exercises should not be done without instructions from the nurse.

Question 4

Which care measure causes the blood vessels to constrict, resulting in less bleeding and decreased tissue swelling?

Accepted Answer

Cold applications reduce pain and swelling and decrease bleeding. Heat application dilates blood vessels, resulting in increased bleeding and tissue swelling. Range-of-motion exercises may decrease swelling, but not bleeding.

Question 5

The person at high risk for injury from heat or cold applications is a client:

Accepted Answer

Fair-skinned people, older people, very young people, chronically ill people, and people with impaired sensation are all vulnerable to injury from heat and cold applications. There is no known relationship between allergies and risk for heat or cold injuries.

Question 6

When a client has a cold pack applied to the foot, the nurse should be notified immediately if the nursing assistant sees that the foot is:

Accepted Answer

The improper application of cold to the foot could cause pale skin that does not return to its normal color quickly after a cold application is removed. This should be reported to the nurse immediately. Dry skin is not unusual and not related to the cold pack. Blistering and bright red skin are results of the improper application of heat not cold.

Question 7

The nurse applied a hot compress to a resident's right knee and delegated for the nursing assistant to monitor the knee every 5 minutes while the compress is in place for the next 20 minutes. The nursing assistant should notify the nurse immediately if the right knee:

Accepted Answer

The nursing assistant should immediately notify the nurse when the right knee receiving the hot compress becomes pale and does not return to the normal coloration of the resident's left knee. This is an untoward finding and indicates a decrease in circulation. It would be expected to observe that the right knee would feel warmer than the left knee because of the heat being applied. An effective treatment increases circulation and would help decrease discomfort in the area and may help improve the mobility of the joint.

Question 8

A nursing assistant suspects that a resident is in pain when the resident:

Accepted Answer

A resident's nonverbal communication may tell the nursing assistant that the resident is in pain. A resident's facial expression or a change in behavior may be the only sign that the resident is experiencing pain. The other options may be a result of not being hungry, tiredness, or depression.

Question 9

A back massage is particularly important for a resident who is at risk for:

Accepted Answer

A back massage is relaxing for the client or resident and helps to prevent the development of pressure ulcers. Although appropriate for the other residents to provide relaxation, the prevention of pressure ulcers is the most important of the reasons provided.

Question 10

To which client should the nursing assistant avoid administering a back massage?

Accepted Answer

As with any personal care procedure, always check with a nurse or read the person's nursing care plan before beginning a massage on a person who has fractured ribs or a back injury. Unless they refuse, the other individuals will likely benefit from a back massage.

Question 11

What can a nursing assistant do to help an older adult resident develop good sleep patterns? Select all that apply.

Accepted Answer

Encourage increased physical activity during the day. Physical activity in the evening does not promote better sleep at night. Limit time for naps during the day. Although a short nap during the day can help an older person meet sleep requirements, taking too many naps or naps that are too long can negatively affect the person's ability to sleep at night. Avoid giving the person beverages with caffeine (such as regular coffee, tea, or cola) in the afternoon or evening. Promote relaxation by giving the person a warm bath in the evening, or providing a massage. Finding out the person's normal bedtime routines, and following them as closely as possible, is also important for promoting relaxation and sleep. Create a comfortable environment for sleeping. Straighten the bed linens and fluff the pillows. Provide a warm blanket.

Question 12

The nursing assistant notices that the client appears to be in pain. What should the nursing assistant do to help the client manage the pain? Select all that apply.

Accepted Answer

Although giving medications is beyond the scope of practice for most nursing assistants, the assistant plays an important role in helping the person manage pain by reporting requests for medication to the nurse promptly. People who need narcotics to control their pain should be encouraged to ask for medication before the pain becomes too intense. Only massage the area if approved by the RN or if it is included on the plan of care. Heating pads are used only when prescribed. Residents can be burned by the heat if left in place for too long.

Question 13

When a resident appears to be in pain, which question(s) should the nursing assistant ask the resident before notifying the nurse? Select all that apply.

Accepted Answer

Since pain is subjective, it is best to ask the person questions to get more details about the pain before reporting to the nurse. Questions to ask may include the following: Where is the pain? How does the pain feel (e.g., is it throbbing, aching, sharp, dull)? How long have you been feeling this pain? Does anything make the pain feel better (or worse)? How intense is the pain (Ask the person to rate the pain on a scale of 1 to 10)? Asking the client to provide information on the pain getting worse or what is causing the pain will be done by the nurse.

Question 14

Which intervention(s) related to dry heat application may result in the client developing a burn? Select all that apply.

Accepted Answer

Placing a dry heat application under a body part can trap too much heat between the person's body and the mattress (or another surface), resulting in a burn. Covering a dry heat application with the bed linens can trap too much heat between the person's body and the bed linens. Wrap dry heat or cold applications (e.g., hot water bottles, ice bags) in a towel before applying them to the person's skin. Always check to make sure the towel is in place between the application and the person's skin. The towel is a protective layer between the person's skin and the application. If applied directly to a person's skin, dry cold or heat can cause severe burns and blisters. Never leave a heat or cold application in place for longer than 20 minutes. Wrap dry heat (e.g., hot water bottles) in a towel before applying them to the person's skin. Check the skin underneath a heat application every 5 minutes. In general, a microwave is not used to heat such items as the temperature may get too hot and burn the skin.

Question 15

Place the steps listed below into the correct sequence for "giving a moist cold application" to the resident with a sore, swollen knee.
A) Leave the compress in place for the designated time of 20 minutes.
B) Straighten the bed linens and make sure the client is in good body alignment.
C) Put the ice in the bath basin and fill the basin with cold water at the sink.
D) Remove the compress and carefully dry the skin.
E) Position the person comfortably and expose only the knee area to be treated.
F) Moisten the compress with ice water; wring out the compress and apply to knee.

Accepted Answer

The steps to performing this procedure are listed on page 626. Review the Procedure 27-2, Giving a Moist Cold Application.

Question 16

After a fall, the resident's knee is swollen, so the nurse has elevated the leg on pillows and placed an ice pack on the knee. The nursing assistant monitors the treatment for the next 20 minutes and should immediately report if the:

Accepted Answer

A report of numbness from the resident is not a normal finding and should be immediately reported to the nurse. This could signal issues with circulation. An ice pack will normally cause the skin to feel cool to touch. The nursing assistant could change the damp towel during the check. The gauze is present to help hold the ice pack in place and should be loose and not tightly applied.

Question 17

How can the nursing assistant best prepare a new resident for the first night at the facility?

Accepted Answer

To help the resident have a peaceful night of sleep, the nursing assistant should ask what the resident usually does to fall asleep and provide those measures. Using what helps the nursing assistant to fall asleep may not help the resident. Not all people like a fluffed pillow, a warm blanket, music, or night light.

Question 18

The nursing assistant enters the room of a resident to help the resident to turn and finds that the resident's family provided a dry heating pad, which the resident has under their back. What is the appropriate action for the nursing assistant to take?

Accepted Answer

The nursing assistant observes that the resident has a heating pad from outside the facility that has not been ordered by a physician. The assistant should explain that the heating pad needs to be checked and ordered by the facility before it can be used by the resident. Taking it away without explanation is seen by the resident as theft. The nursing assistant should not continue to monitor the use of the heating pad without the nurse delegating it.

Question 19

The nursing assistant is caring for a hospitalized client who requires an aquamatic pad to the right shoulder. What is the first action for the nursing assistant to take when the water level is low and the covering is wet?

Accepted Answer

The nursing assistant observes that the covering of the aquamatic pad is wet and the water reservoir is low and should troubleshoot the issue by checking that the connections are tight. Filling the reservoir with more water without finding a reason for the wet pad covering will not solve the issue. If it is not the connections, then there could be a hole in the pad itself. The client could be sweating, but that would not explain why the reservoir is low along with a wet pad covering. Getting another machine is the last resort because it will take time for it to get set up and at the prescribed temperature.

Question 20

The nursing assistant is caring for a client who arrived on the unit after wrist surgery whose left arm is elevated on pillows with an ice pack in place. What finding should the nursing assistant report immediately to the nurse?

Accepted Answer

The nursing assistant observes for circulation, color, movement, temperature, and sensation while cold therapy is being administered every 5 minutes and observes that there is fresh bloody drainage on the dressing and should report this new finding immediately to the nurse. Cold therapy should decrease edema or swelling and bleeding. The client just arrived after surgery so the client is going to be sleepy and most likely will not be able to respond when asked about numbness, tingling, burning, or discomfort. The skin of the fingers distal to the surgical site matches the color of the skin of the nonsurgical hand, and the client moves the fingers that help support healthy circulation.

Quiz 27: Assisting With Comfort