A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)
Apply a compression bandage to the client's ankle.
Apply heat to the client's ankle.
Encourage the range of motion of the client's foot.
Elevate the client's foot.
Check the client's toes for color, temperature, and sensation.
Correct Answer : A,D,E
These are the correct interventions that the nurse should take. Applying a compression bandage to the client's ankle can help reduce swelling and provide support to the injured area. Elevating the client's foot can also help reduce swelling by promoting venous return. Checking the client's toes for color, temperature, and sensation is important to assess for any potential nerve or vascular damage.
Applying heat to the client's ankle is not recommended as it can increase swelling and inflammation. Encouraging range of motion of the client's foot is also not recommended as it can cause further injury to the affected area.
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Related Questions
Correct Answer is C
Explanation
The first action the nurse should perform is to check the client's temperature. A headache and stiff neck can be symptoms of meningitis, which is an inflammation of the membranes surrounding the brain and spinal cord. Meningitis can be caused by a bacterial or viral infection and is often accompanied by a fever. Checking the client's temperature can help determine if the client has a fever and if further evaluation for meningitis is necessary.
Obtaining a throat culture specimen is not the first action the nurse should take.
Performing a complete blood count is not the first action the nurse should take.
Administering an oral analgesic is not the first action the nurse should take.
Correct Answer is C
Explanation
To prevent autonomic dysreflexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreflexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full¹.
Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreflexia.
Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreflexia.
Elevating the client's head is important but not an intervention to prevent autonomic dysreflexia.
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