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."

Answer and Explanation

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.

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Correct Answer is D

Explanation

D. This is the correct characteristic of decerebrate posturing. Decerebrate posturing is characterized by rigid extension and pronation (turning inward) of the arms and legs. It indicates severe neurological dysfunction and increased intracranial pressure, often involving damage to the brainstem.

A. This characteristic is not associated with decerebrate posturing. Adduction refers to movement toward the midline of the body, which is not typically observed in decerebrate posturing.

B. This description is not characteristic of decerebrate posturing. Decerebrate posturing involves extension, not flexion, of the upper extremities, along with extension and pronation (not adduction) of the lower extremities.

C. Flaccid paralysis refers to the absence of muscle tone and movement, which is not characteristic of decerebrate posturing. Decerebrate posturing involves increased muscle tone and abnormal, rigid extension of the arms and legs.

A. Warm extremities B. Wheezing C. Nasal flaring D. Retraction of sternal muscles E. Oxygen saturation 95%

Correct Answer is ["B","C","D"]

Explanation

B. Wheezing is a common symptom of asthma exacerbation and can indicate airway obstruction. Wheezing may worsen during an asthma attack, suggesting deterioration in respiratory status.

C. Nasal flaring is a sign of increased respiratory effort and can occur during respiratory distress. In a child with asthma, nasal flaring may indicate worsening airway obstruction and increased work of breathing, suggesting deterioration in respiratory status.

D. Retraction of sternal muscles, also known as intercostal retractions, occurs when the muscles between the ribs are drawn inward during inspiration, indicating increased effort to breathe. Intercostal retractions are a sign of respiratory distress and can occur in children with asthma during exacerbations, particularly when airway obstruction is severe.

A. Warm extremities are not typically indicative of deterioration in respiratory status in a child with asthma. In fact, warm extremities may suggest adequate peripheral perfusion.

E. An oxygen saturation of 95% is within the normal range for most children and may not necessarily indicate deterioration in respiratory status. However, oxygen saturation should be interpreted in conjunction with other clinical signs and symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

Correct Answer is D

Explanation

A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select All that Apply.)

Correct Answer is ["B","C","D"]

Explanation

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