A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

“I’ll apply ice to my ankle for 20 minutes every hour.”

“I’ll rewrap my ankle starting from the knee down.”

“I’ll walk on my ankle for 10 minutes every hour.”

“I’ll put a heating pad on my ankle at bedtime tonight.”

Answer and Explanation

The Correct Answer is A

A. "I’ll apply ice to my ankle for 20 minutes every hour."

This is the correct choice. Applying ice for a specified duration (20 minutes) every hour is a standard recommendation for managing swelling and pain associated with an ankle sprain. It helps reduce inflammation and provides relief.

B. "I’ll rewrap my ankle starting from the knee down."

This statement indicates a misunderstanding. When rewrapping an ankle, it should be done from the bottom (proximal) to the top (distal) to provide proper compression. Starting from the knee down is not the correct technique.

C. "I’ll walk on my ankle for 10 minutes every hour."

This statement may indicate a misunderstanding or potential for harm. Immediate weight-bearing or walking on an injured ankle, especially after a sprain, is generally not recommended. Rest is often a key component of initial management.

D. "I’ll put a heating pad on my ankle at bedtime tonight."

This statement may indicate a misunderstanding. Heat is not typically recommended in the initial stages of treating an acute injury like an ankle sprain, as it may increase inflammation. Ice (cold therapy) is usually the preferred modality early on to reduce swelling and pain.

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Correct Answer is A

Explanation

A. Tenting

Tenting refers to the delayed recoil of the skin when pinched. In a dehydrated state, the skin loses elasticity, leading to tenting due to decreased skin turgor. This is a specific sign of fluid-volume deficit.

B. Protruding eyeballs

Protruding eyeballs are not typically associated with dehydration. This could be related to other conditions such as thyroid dysfunction, but it is not a specific indicator of fluid-volume deficit.

C. Elevated blood pressure

Elevated blood pressure is not a typical sign of dehydration. In fact, dehydration often leads to a decrease in blood pressure due to reduced blood volume.

D. Dry mucous membranes

Dry mucous membranes can be an indication of dehydration, but in the context of the question, tenting (Option A) is a more specific sign related to skin turgor and is commonly assessed when evaluating for dehydration.

A. “I wish I didn’t have to attach the electrodes to my skin.” B. “It’s unfortunate that I have to be in the hospital for this treatment.” C. “I’ll need to shave the hair off the skin where I place the electrodes.” D. “I hope I don’t have to take as many pain pills.”

Correct Answer is B

Explanation

A. “I wish I didn’t have to attach the electrodes to my skin.”

This statement reflects a common sentiment. Attaching electrodes to the skin is part of using TENS, and it's a non-invasive procedure where electrodes are placed on the skin surface to deliver electrical impulses for pain relief.

B. “It’s unfortunate that I have to be in the hospital for this treatment.”

This statement indicates a need for further teaching. TENS is typically an outpatient treatment, and individuals can use TENS units at home after receiving appropriate instructions and training. It does not require being in the hospital.

C. “I’ll need to shave the hair off the skin where I place the electrodes.”

This statement is accurate. To ensure proper contact and effectiveness, it is often recommended to shave or trim the hair in the area where the electrodes will be placed.

D. “I hope I don’t have to take as many pain pills.”

This statement reflects an understanding of the potential benefits of TENS. TENS is used as an adjunct therapy to help manage pain, and one of its goals may be to reduce the need for pain medications.

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A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

Nursing Test Bank

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