A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?

"I will apply heat to my affected ankle to decrease swelling."

"I can bear full weight on my affected ankle."

"I can dangle my affected ankle from the edge of the bed."

"I will wrap my affected ankle with an elastic bandage."

Answer and Explanation

The Correct Answer is D

Choice A Reason:
"I will apply heat to my affected ankle to decrease swelling." Heat application is generally not recommended for acute injuries like ankle sprains. Heat can increase blood flow and potentially worsen swelling. Cold therapy (like ice) is typically advised in the early stages to reduce inflammation and swelling.
Choice B Reason:
"I can bear full weight on my affected ankle." For a grade 2 ankle sprain, bearing full weight on the affected ankle might not be advisable initially. Grade 2 sprains involve partial tearing of ligaments and usually require some period of rest or limited weight-bearing to allow healing.
Choice C Reason:
"I can dangle my affected ankle from the edge of the bed. “Dangling the affected ankle from the edge of the bed is a common recommendation to help with gentle movement and improve blood flow without putting excessive stress on the injured ankle. This activity can aid in the recovery process and is often recommended.
Choice D Reason:
"I will wrap my affected ankle with an elastic bandage. “Wrapping the affected ankle with an elastic bandage is a supportive measure recommended for managing ankle sprains. It helps provide compression, support, and stabilization to the injured area, assisting in reducing swelling and providing comfort.

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Correct Answer is A

Explanation

Choice A Reason:
Checking the client for ecchymosis is appropriate. Thrombocytopenia increases the risk of bleeding and bruising, so monitoring for ecchymosis (bruising) is essential to detect any signs of bleeding. Ecchymosis can occur more easily in individuals with low platelet counts.
Choice B Reason:
Initiating protective isolation for the client is typically unnecessary solely due to thrombocytopenia. Protective isolation is generally for clients with conditions that compromise their immune system or make them more susceptible to infections.
Choice C Reason:
Administering ibuprofen for a mild headache might not be advisable in someone with thrombocytopenia because ibuprofen can affect platelet function and potentially increase the risk of bleeding.
Choice D Reason:
Instructing the client to shave with a disposable razor isn't recommended because using a sharp blade can increase the risk of cuts and bleeding in someone with a low platelet count. Using an electric razor or avoiding shaving might be safer options to prevent injury and bleeding.

A. LDL B. INR C. BUN D. Hct

Correct Answer is B

Explanation

Choice A Reason:

LDL (Low-Density Lipoprotein) is incorrect. This is a type of cholesterol and is not specifically monitored in relation to warfarin therapy.

Choice B Reason:

INR (International Normalized Ratio) is correct. Warfarin is an anticoagulant medication, and its dosage needs to be adjusted based on the INR levels. INR monitoring helps assess the clotting tendency of the blood and ensures that the dosage of warfarin is within the therapeutic range to prevent blood clots without causing excessive bleeding.

Choice C Reason:

BUN (Blood Urea Nitrogen) is incorrect. This value is primarily used to assess kidney function and is not directly related to monitoring warfarin therapy.

Choice D Reason:

Hct (Hematocrit) is incorrect. This measures the percentage of red blood cells in the blood and is not directly related to monitoring warfarin therapy for atrial fibrillation.

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A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?

Correct Answer is B

Explanation

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