A client presents the emergency department with a Grade II ankle sprain. Which of the following interventions should the nurse implement?

Encourage the client to walk on the injured ankle to promote circulation.

Immerse the ankle in want water immediately after the in

Apply ice to the affected ankle for the first 24-72 hours.

Perform deep tissue massage on the injured area to reduce pain.

Answer and Explanation

The Correct Answer is C

A. Encourage the client to walk on the injured ankle to promote circulation. Weight-bearing activities should be avoided initially after a Grade II sprain to prevent further injury.

B. Immerse the ankle in warm water immediately after the injury. Ice, rather than warmth, is recommended immediately following an injury to reduce swelling and inflammation.

C. Apply ice to the affected ankle for the first 24-72 hours. Applying ice for 24-72 hours helps reduce swelling and pain by causing vasoconstriction and controlling inflammation in the acute phase.

D. Perform deep tissue massage on the injured area to reduce pain. Massaging a newly sprained ankle can aggravate inflammation and cause additional tissue damage.

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Correct Answer is D

Explanation

A. Pulmonary Function Test (PFT). PFTs assess lung function but do not provide diagnostic information for infections like pneumonia.

B. Electrocardiogram (ECG). An ECG assesses heart function and would not help in diagnosing a respiratory infection like pneumonia.

C. Complete Blood Count (CBC). A CBC may indicate infection through elevated white blood cells, but it does not confirm pneumonia or identify its location in the lungs.

D. Chest X-ray. A chest X-ray is the most useful diagnostic tool to confirm pneumonia. It can reveal infiltrates or consolidation in the lungs, which are characteristic of pneumonia.

A. Increased pulse, respirations and blood pressure with dysphagia and respiratory distress B. Hypotension, diarrhea and increased salivation C. Bradycardia and hypothermia D. Tachypnea and hyperactive deep tendon reflexes

Correct Answer is A

Explanation

A. Increased pulse, respirations and blood pressure with dysphagia and respiratory distress. A myasthenic crisis is characterized by severe muscle weakness that can lead to respiratory failure, dysphagia, and increased vital signs due to the stress of respiratory distress.

B. Hypotension, diarrhea, and increased salivation. These symptoms are more indicative of a cholinergic crisis, which is due to excess acetylcholine.

C. Bradycardia and hypothermia. Bradycardia and hypothermia are not characteristic signs of a myasthenic crisis.

D. Tachypnea and hyperactive deep tendon reflexes. While tachypnea can occur in respiratory distress, hyperactive reflexes are not typical in myasthenic crisis, as it involves neuromuscular weakness.

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A client presents the emergency department with a Grade II ankle sprain. Which of the following interventions should the nurse implement?

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