A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?
Ask the patient to try bearing weight on the ankle
Elevate the ankle above heart level
Apply a warm moist pack to the ankle
Assess the ankle's passive range of motion (ROM)
The Correct Answer is B
Choice A reason: Asking the patient to try bearing weight on the injured ankle is not appropriate at this stage. Bearing weight can cause further injury or exacerbate the swelling and pain. The initial treatment should focus on reducing swelling and providing support.
Choice B reason: Elevating the ankle above heart level is appropriate because it helps to reduce swelling by promoting venous return and decreasing fluid accumulation in the affected area. Elevation is a standard first aid measure for managing acute injuries and swelling.
Choice C reason: Applying a warm moist pack to the ankle is not advisable immediately after an injury. In the acute phase, cold therapy (ice) is recommended to reduce swelling and pain. Warm therapy is more appropriate during the recovery phase, once swelling has subsided.
Choice D reason: Assessing the ankle's passive range of motion (ROM) may be necessary later, but not immediately upon arrival. The priority is to manage pain and swelling first. ROM assessments can be painful and might worsen the injury if conducted too soon.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hypotension, chills, and thirst are not characteristic signs and symptoms of a thyroid storm. Hypotension generally indicates low blood pressure, while chills and thirst are less specific symptoms that do not particularly point to thyroid storm.
Choice B reason: Lethargy, confusion, and bradycardia are not typical indicators of a thyroid storm. These symptoms might be present in other conditions but are not generally associated with the severe hypermetabolic state seen in thyroid storms.
Choice C reason: Bradycardia, hypotension, and low urine output are also not typical signs of a thyroid storm. Bradycardia (slow heart rate) and hypotension (low blood pressure) are more likely associated with severe hypothyroidism or other conditions, not the hyperactive state of a thyroid storm.
Choice D reason: Fever, tachycardia, and tremors are classic signs of a thyroid storm. A thyroid storm is a life-threatening condition characterized by an excessive amount of thyroid hormones, leading to hypermetabolic activity. This results in symptoms like a high fever, rapid heart rate (tachycardia), and tremors.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: The nurse would include making decisions about health and lifestyle modifications to manage MS because this helps the patient to make informed choices that can alleviate symptoms and improve their quality of life. Modifying aspects such as diet, exercise, and stress management can play a significant role in managing the disease and preventing relapses.
Choice B reason: Curing the disease is not currently a feasible outcome for multiple sclerosis, as there is no known cure. The focus of the care plan is typically on managing symptoms, slowing the progression of the disease, and improving the patient's quality of life rather than curing the disease.
Choice C reason: Maintaining or improving muscle strength and mobility is crucial for patients with MS, as the disease often affects muscle control and strength. Including this outcome in the care plan helps to reduce the risk of falls, improve the patient's ability to perform daily tasks, and enhance overall physical function.
Choice D reason: Maintaining urinary continence is an important aspect of care for MS patients, as the disease can affect bladder control. Including this outcome helps to ensure the patient's comfort and dignity, prevent urinary tract infections, and improve their quality of life.
Choice E reason: Maintaining independence in performing activities of daily living (ADLs) is essential for patients with MS to ensure they can continue to perform tasks such as bathing, dressing, and eating. This outcome supports the patient's self-esteem and promotes a sense of autonomy.
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