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. The correct action would be to place the client on NPO (Nothing by Mouth) status, option D. This is because a decreased level of consciousness can increase the risk of aspiration.

A. Liver biopsy is not indicated for suspected meningitis with a decreased level of consciousness. Liver biopsy is a procedure used to obtain a sample of liver tissue for diagnostic purposes, typically to evaluate liver function or diagnose liver diseases.

B. A protective environment (option B) is more related to immunocompromised patients. In the case of decreased level of consciousness, preventing aspiration is key.

C. Dorsal recumbent position refers to lying on the back with the knees flexed. While this position may be suitable for certain medical procedures or examinations, it is not specifically indicated for a client with suspected meningitis and a decreased level of consciousness.

A. Bluish-green discharge from the ear canal B. Increase in appetite C. Erythema and edema of the affected auricle D. Tugging on the affected ear lobe

Correct Answer is D

Explanation

D. Tugging or pulling on the affected ear lobe is a classic sign of otitis media in infants. The discomfort or pain caused by inflammation and pressure in the middle ear may lead the infant to tug or rub the affected ear in an attempt to alleviate discomfort.

A. Bluish-green discharge from the ear canal is not a typical finding in otitis media. Otitis media is characterized by inflammation and fluid accumulation in the middle ear, which may not result in discharge unless there is a secondary bacterial infection or perforation of the eardrum.

B. An increase in appetite is not a typical finding in otitis media. In fact, many children with otitis media may experience a decrease in appetite due to discomfort, pain, and difficulty swallowing or chewing.

C. Erythema (redness) and edema (swelling) of the affected auricle (outer ear) are not typically associated with otitis media. Otitis media primarily affects the middle ear, where inflammation and fluid accumulation occur behind the eardrum.

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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

A nurse is assisting with the care of a client who has suspected meningitis and a decrease level of consciousness. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings?

Correct Answer is D

Explanation

A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect?

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