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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A bounding distal pulse indicates impaired venous return in the affected arm. A bounding pulse is a strong and forceful pulse that can be a sign of increased blood flow to the area. In this case, it may indicate that blood is not returning from the affected arm as it should.
a. Auscultation of lungs revealing wheezing is not related to venous return in the affected arm. Wheezing is a high-pitched whistling sound made while breathing and is usually a sign of a respiratory problem.
c. Fever is also not related to venous return in the affected arm. Fever is an increase in body temperature and is usually a sign of an infection or inflammation.
d. Pain unrelieved by opioid analgesics is not an indication of impaired venous return in the affected arm. Pain can have many causes and may not be relieved by opioid analgesics for various reasons.
Correct Answer is ["B","C","E"]
Explanation
A nurse collecting data from a client who has an exacerbation of gout should expect to find edema, tophi, and erythema. Gout is a type of arthritis that occurs when urate crystals accumulate in the joints, causing inflammation and intense pain. Edema (swelling) is a common symptom of gout⁴. Tophi are deposits of urate crystals that can form under the skin in people with chronic gout³. Erythema (redness) is another common symptom of gout⁴.
a. Tight skin is not a common symptom of gout.
d. Symmetrical joint pain is not a common symptom of gout, as it usually affects only one joint at a time.
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