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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 A

Explanation

A. Palpating the femoral pulse is an essential part of assessing the neurovascular status of a client with a femur fracture. The presence and strength of the femoral pulse can indicate adequate blood flow to the lower extremity.

B. While measuring the circumference of the thigh can provide some information about swelling or changes in the size of the limb, it does not directly assess neurovascular status.

C. Monitoring the client's calf for edema is important for assessing for signs of deep vein thrombosis (DVT) or venous insufficiency, but it is not the primary technique for assessing neurovascular status.

D. Instructing the client to wiggle his toes is a way to assess motor function and nerve function, which is part of the neurovascular assessment. However, it is not the initial step in assessing neurovascular status in a client with an unrepaired femur fracture. The femoral pulse should be assessed first to ensure adequate blood flow.

A. Fat embolism syndrome B. Pulmonary embolism C. Acute compartment syndrome D. Osteomyelitis

Correct Answer is C

Explanation

A. Fat embolism syndrome - This is characterized by respiratory distress, altered mental status, and petechial rash. It is not associated with increasing edema.

B. Pulmonary embolism - This occurs when a blood clot (usually from the legs) travels to the lungs and can present with symptoms like chest pain, shortness of breath, and rapid heart rate. It is not associated with increasing edema around a fracture site.

C. Acute compartment syndrome - This is a serious condition that occurs when increased pressure within a muscle compartment impairs blood supply, leading to tissue ischemia and necrosis. Increasing edema is an early sign of compartment syndrome.

D. Osteomyelitis - This is an infection of the bone and is not typically associated with increasing edema around a fracture site. It may present with local signs of infection like warmth, redness, and tenderness.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Correct Answer is A

Explanation

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications?

Correct Answer is C

Explanation

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