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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Use a blow dryer on a moderate heat setting to dry the cast after showering.
This is not recommended as using a blow dryer on a cast can cause burns. Instead, the cast should be allowed to air-dry or be dried with a fan.
B. Use a cotton swab to relieve itching under the cast.
Inserting objects, including cotton swabs, under the cast can lead to complications such as infection or skin damage. It is not recommended to insert anything into the cast.
C. Report any worsening or unrelieved pain.
This is the correct instruction. Persistent or increasing pain can indicate complications such as swelling, infection, or neurovascular compromise. It is important for the client to promptly report any changes in pain to healthcare providers.
D. Avoid moving the affected leg.
While it's important to limit movement to allow for proper healing, complete immobilization can lead to joint stiffness and muscle atrophy. Gentle range-of-motion exercises for non-weight-bearing areas may be encouraged, but any specific movement instructions should be provided by the healthcare provider. If movement causes significant pain or discomfort, the client should consult the healthcare provider.
Correct Answer is C
Explanation
A. To help the nurse validate the client’s reports of pain
This option suggests that the nurse's actions (straightening bed linens, rubbing the back, assisting with repositioning) are intended to assess or confirm the client's reports of pain. However, these actions are more aligned with providing comfort and assistance with activities of daily living rather than specifically assessing pain. If the client reports pain related to the chest tube, a more focused assessment and intervention would be needed.
B. To increase positive pressure in the chest
This option implies that the nurse's actions could somehow influence the positive pressure in the client's chest, which is not accurate. Positive pressure in the chest is usually related to mechanical ventilation or specific medical interventions. The described actions are more related to comfort and assistance with daily activities.
C. To assist the client with ADLs (Activities of Daily Living)
This is the most appropriate choice. The nurse's actions, such as straightening bed linens, rubbing the back, and assisting with repositioning, align with providing support for the client's daily activities and overall well-being.
D. To modify the client’s perception of pain
This option suggests that the nurse's actions are aimed at altering the client's perception of pain. While comfort measures can contribute to pain management, these specific actions are not typically used to modify perception. If pain is a concern, more direct pain management strategies and assessments would be appropriate.
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