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 ["A","B"]
Explanation
A. Humidified oxygen can help improve oxygenation and relieve respiratory distress by maintaining optimal humidity levels in the airways, which can be beneficial, especially in infants with bronchiolitis who may have increased respiratory secretions and airway inflammation.
B. Monitoring respiratory rate and oxygen saturation allows for early detection of respiratory distress and hypoxemia, which are common complications of bronchiolitis. Regular assessment helps guide interventions and ensures timely escalation of care if needed.
C. Restricting fluid intake is not typically indicated for children with bronchiolitis. In fact, maintaining adequate hydration is crucial for children with respiratory illnesses to help thin respiratory secretions and prevent dehydration.
D. Antibiotics are not routinely indicated for the treatment of bronchiolitis caused by viral pathogens. Bronchiolitis is typically caused by respiratory syncytial virus (RSV) or other viral infections, for which antibiotics are ineffective.
E. Chest physiotherapy is not routinely recommended for the management of bronchiolitis in infants and children. Bronchiolitis is primarily managed with supportive care measures such as humidified oxygen, hydration, and monitoring for respiratory distress.
Correct Answer is B
Explanation
B. Leaning forward with the chin thrust out, often described as the "sniffing position," is a classic sign of airway obstruction, particularly in cases of epiglottitis. This positioning helps to maximize airway patency by opening the airway and reducing the risk of further obstruction.
A. Leaning forward with the chin thrust out is not typically associated with extreme fatigue. Instead, it is a specific positioning often seen in individuals with epiglottitis to help alleviate airway obstruction and facilitate breathing.
C. Leaning forward with the chin thrust out is not indicative of dehydration. Dehydration may present with other signs and symptoms such as dry mucous membranes, decreased urine output, sunken fontanelle (in infants), and poor skin turgor.
D. Pain may be present in a child with epiglottitis but leaning forward with the chin thrust out is not primarily indicative of pain. This positioning is primarily a compensatory mechanism to alleviate airway obstruction rather than a response to pain.
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