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A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take? (Select all that apply.)

Place a compression bandage on the ankle.

Apply heat to the ankle.

Encourage rest.

Elevate the ankle.

Perform passive range-of-motion exercises to the ankle.

Answer and Explanation

Correct Answer : A,C,D,E

A. Place a compression bandage on the ankle.

- This helps reduce swelling and provides support to the injured area.

B. Apply heat to the ankle

- This action is not recommended for acute sprains as it can increase swelling. Cold packs or ice should be used initially to reduce inflammation.

C. Encourage rest.

- Rest is important to allow the ankle to heal properly and prevent further injury.

D. Elevate the ankle.

- Elevating the ankle helps reduce swelling by allowing fluid to drain away from the injured area.

E. Perform passive range-of-motion exercises to the ankle.

- Gentle range-of-motion exercises can help prevent stiffness in the ankle joint. However, it's important to perform these exercises within the limits of comfort and not force any movements.

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Correct Answer is B

Explanation

A. Performing range of motion: This should not be done immediately after applying the cast, as it may compromise the integrity of the cast. Range of motion exercises should be initiated once the cast has fully set and as directed by the healthcare provider.

B. Checking capillary refill distal to the cast: This is the priority after applying the cast. It assesses blood flow to the extremity below the cast. Impaired circulation could lead to serious complications, so it's crucial to monitor capillary refill promptly.

C. Teaching the client about cast care: While providing education about cast care is important, it is not the immediate priority. Ensuring proper circulation is more critical in the initial moments after applying the cast.

D. Managing pain: While pain management is important, it is not the immediate priority after applying the cast. Ensuring proper circulation and assessing for any signs of impairment take precedence. Pain management can be addressed once circulation is confirmed to be adequate.

A. This service focuses on teaching the primary caregiver to meet the client's needs. B. The emphasis is on the client's complete recovery from the illness or injury. C. This service began with the client's admission to the hospital. D. Services are centered in long-term care facilities.

Correct Answer is A

Explanation

A. This option is correct. Rehabilitative care often involves educating the primary caregiver on how to assist the client in their recovery process.

B. This option suggests a focus on complete recovery, but rehabilitative care may also focus on adapting to new circumstances if complete recovery is not possible.

C. This option refers to the initiation of services, which may not specifically pertain to rehabilitative care.

D. This option incorrectly associates rehabilitative care exclusively with long-term care facilities. While rehabilitative care may occur in such facilities, it can also occur in other settings.

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A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take? (Select all that apply.)

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