A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?
Apply the elastic compression dressing tight enough so the toes and ankle become numb.
Place moderate weight on the affected leg when walking.
Elevate the affected ankle to the level of the heart.
Apply heat during the first 24 hr.
The Correct Answer is C
The nurse should instruct the client to elevate the affected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood flow to the injured area. This is an important part of the RICE (Rest, Ice, Compression, Elevation) method for treating sprains and strains.
a. The elastic compression dressing should not be applied so tight that it causes numbness in the toes and ankle.
b. The client should avoid placing weight on the affected leg when walking until advised by a healthcare provider.
d. Heat should not be applied during the first 24 hours after a sprain as it can increase swelling and inflammation.
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Related Questions
Correct Answer is C
Explanation
When contributing to the plan of care for a client who is postoperative following a total hip arthroplasty, the nurse should include information on preventing hip flexion of the affected extremity. This can help prevent dislocation of the new hip joint and promote healing.
a. Positioning the lower extremities so that they are touching is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the lower extremities should be determined by the surgeon's instructions and the client's comfort.
b. Ensuring that the client's heels are touching the bed is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the heels should be determined by the surgeon's instructions and the client's comfort.
d. Instructing the client to avoid movement of the affected leg is not necessary for a client who is postoperative following a total hip arthroplasty. The client will need to begin moving and exercising the affected leg as part of their rehabilitation and recovery.
Correct Answer is A
Explanation
The first action the nurse should take is to test the drainage for glucose. Clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help determine if it is CSF.
b. Taking the client's temperature is not the first action the nurse should take.
c. Notifying the charge nurse is important but not the first action the nurse should take.
d. Placing a dressing under the client's nose is not the first action the nurse should take.
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