A nurse is teaching a client who has a new second-degree ankle sprain. Which of the following instructions should the nurse include in the teaching? Select all that apply.

Apply intermittent ice to the affected ankle for the first 48 hours.

Wrap the affected ankle with an elasticized compression bandage.

Apply full weight-bearing on the affected ankle.

Elevate the affected ankle above the level of the heart.

Apply a heating pad intermittently to the affected ankle after 48 hours.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Apply intermittent ice to the affected ankle for the first 48 hours

Applying ice intermittently to the affected ankle for the first 48 hours helps reduce swelling and inflammation. Ice should be applied for 15-20 minutes every 2-3 hours during the initial phase of injury management. This practice is part of the RICE (Rest, Ice, Compression, Elevation) protocol commonly used for sprains and strains.

Choice B reason: Wrap the affected ankle with an elasticized compression bandage

Wrapping the affected ankle with an elasticized compression bandage helps to minimize swelling and provide support to the injured area. Compression bandages should be snug but not too tight to avoid restricting blood flow. This is another component of the RICE protocol.

Choice C reason: Apply full weight-bearing on the affected ankle

Applying full weight-bearing on the affected ankle is not recommended immediately after a second-degree sprain. The ankle needs time to heal, and weight-bearing should be gradually reintroduced as pain and swelling decrease. Initially, the client should avoid putting weight on the injured ankle to prevent further damage.

Choice D reason: Elevate the affected ankle above the level of the heart

Elevating the affected ankle above the level of the heart helps reduce swelling by promoting venous return and decreasing fluid accumulation in the injured area. This is an essential part of the RICE protocol and should be done as much as possible during the first 48 hours.

Choice E reason: Apply a heating pad intermittently to the affected ankle after 48 hours

Applying a heating pad intermittently to the affected ankle after 48 hours can help increase blood flow and promote healing. Heat therapy should be used after the initial acute phase (first 48 hours) when swelling has subsided. Heat can help relax muscles and reduce stiffness in the injured area.

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Correct Answer is D

Explanation

Choice A reason: Tea

Tea contains polyphenols and tannins, which can inhibit the absorption of nonheme iron. Therefore, it is not recommended to consume tea with iron-rich foods if the goal is to enhance iron absorption.

Choice B reason: Dried beans

Dried beans are a good source of nonheme iron, but they do not enhance its absorption. In fact, beans contain phytates, which can inhibit iron absorption. While they are beneficial for iron intake, they should be consumed with foods that enhance iron absorption, such as those rich in vitamin C.

Choice C reason: Milk

Milk contains calcium, which can inhibit the absorption of both heme and nonheme iron. Therefore, it is not recommended to consume milk with iron-rich foods if the goal is to enhance iron absorption.

Choice D reason: Tomato juice

Tomato juice is rich in vitamin C, which significantly enhances the absorption of nonheme iron. Consuming vitamin C-rich foods like tomato juice with iron-rich foods can improve the body’s ability to absorb iron, making it an excellent choice for individuals with iron deficiency anemia.

A. Ask the client to blow his nose. B. Suction the nostril. C. Notify the physician. D. Test the drainage for glucose.

Correct Answer is D

Explanation

Choice A reason: Ask the client to blow his nose

Asking the client to blow his nose is not advisable in this situation. Blowing the nose can increase intracranial pressure and potentially worsen the condition by causing more cerebrospinal fluid (CSF) to leak or even lead to further complications. Therefore, this action should be avoided.

Choice B reason: Suction the nostril

Suctioning the nostril is also not recommended. This action can introduce infection and increase the risk of further complications. It is important to handle any potential CSF leak with care to prevent infection and other issues.

Choice C reason: Notify the physician

While notifying the physician is important, it is not the immediate first step. The nurse should first confirm whether the clear drainage is CSF. Once confirmed, notifying the physician would be the next appropriate step.

Choice D reason: Test the drainage for glucose

Testing the drainage for glucose is the correct first action. CSF contains glucose, so a positive glucose test would confirm that the drainage is indeed CSF. This is a critical step in diagnosing a CSF leak, which can occur with basal skull fractures. Confirming the presence of CSF will guide further medical interventions and management.

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A nurse is teaching a client who has a new second-degree ankle sprain. Which of the following instructions should the nurse include in the teaching? Select all that apply.

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