The nurse is providing instructions about how to treat a sprained ankle. What statement by the mother does the nurse recognize as indicative of a need for additional teaching?
"Put an ice pack on the ankle, alternating 20 minutes on with 20 minutes off."
"Wrap the ankle in an Ace bandage for support."
"Keep the leg elevated when sitting"
"Apply warm compresses to the ankle for the first 24 hours."
The Correct Answer is D
D. Warm compresses or heat therapy are not recommended for the initial management of a sprained ankle, especially within the first 24 hours. Heat can increase blood flow and exacerbate swelling and inflammation, which may worsen pain and delay healing.
A. Applying ice packs in this manner helps reduce inflammation and swelling, which are common after a sprain. Alternating ice application with periods of rest allows for effective cooling without causing tissue damage.
B. Wrapping the ankle in an Ace bandage can provide compression and support, which may help reduce swelling and stabilize the joint during the healing process. However, it's important not to wrap the bandage too tightly, as this can impair circulation.
C. Elevating the leg when sitting helps reduce swelling by promoting venous return and preventing fluid accumulation in the injured area. Keeping the ankle elevated above the level of the heart whenever possible is recommended for optimal swelling reduction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. The narrowing of the aorta results in increased resistance to blood flow beyond the constriction, leading to decreased blood pressure in the lower body, including the legs. As a result, the blood pressure in the arms may be significantly higher than in the legs, creating a notable blood pressure gradient between the upper and lower extremities.
A. Pulmonary edema is not a typical manifestation of coarctation of the aorta. Coarctation of the aorta involves a narrowing of the aortic arch, typically occurring after the branching of the vessels supplying the upper body.
C. Severe cyanosis is not typically associated with coarctation of the aorta. Cyanosis, a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood, is more commonly seen in conditions affecting pulmonary circulation or oxygenation of the blood, such as congenital heart defects involving right-to-left shunting of blood.
D. A machine-like murmur is not a typical finding in coarctation of the aorta. The characteristic murmur associated with coarctation of the aorta is a systolic ejection murmur heard best over the back or left axilla.
Correct Answer is ["A","D","E"]
Explanation
A. Decreased cardiac output in heart failure can lead to poor perfusion of the extremities, resulting in cool skin and decreased urine output due to reduced renal perfusion and impaired kidney function.
D. Poor feeding is often observed due to increased respiratory effort, tachypnea, and fatigue associated with heart failure. Additionally, infants may exhibit failure to thrive or inadequate weight gain despite increased caloric intake due to metabolic demands and inefficient utilization of nutrients.
E. Tachypnea and respiratory distress occur due to pulmonary congestion and increased respiratory effort in response to heart failure. Infants may exhibit signs such as nasal flaring, grunting, retractions, and cyanosis.
B. Bradycardia and hypotension are not typical manifestations of heart failure in infants. Instead, infants with heart failure often present with tachycardia (rapid heart rate) as a compensatory mechanism to maintain cardiac output. Hypotension may occur in severe cases but is not a common finding.
C. Increased appetite and excessive weight gain are not typical manifestations of heart failure in infants. Infants with heart failure often experience poor feeding and failure to thrive due to inadequate cardiac output and oxygen delivery to meet metabolic demands.
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