A nurse at an urgent care center is caring for four clients who all have leg or foot injuries. Which of the following client reports should suggest to the nurse that the client has an ankle sprain?
Was hit by another soccer player on the field
Twisted his foot while running bases during a baseball game
Has ankle pain after running a 16 km (10 mile) race
Dropped a 4.5 kg (10 lb) weight on his lower leg at a health club
The Correct Answer is B
A. Was hit by another soccer player on the field - This suggests a possible collision injury, which may result in various types of leg or foot injuries, but it doesn't specifically point to an ankle sprain.
B. Twisted his foot while running bases during a baseball game - This mechanism of injury is consistent with an ankle sprain. Twisting the foot during a sudden movement can cause stretching or tearing of ligaments around the ankle.
C. Has ankle pain after running a 16 km (10 mile) race - This suggests an overuse or strain injury, which could include various types of leg injuries, but it doesn't specifically point to an ankle sprain.
D. Dropped a 4.5 kg (10 lb) weight on his lower leg at a health club - This suggests a potential crush or impact injury to the lower leg, which may result in various types of leg injuries, but it doesn't specifically point to an ankle sprain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Inserting sterile packing into the nares is not indicated in this situation. Clear fluid drainage from the nose may be cerebrospinal fluid (CSF), and packing could cause further complications.
B. Allowing the drainage to drip onto a sterile gauze pad is the appropriate initial action. Clear fluid drainage from the nose after a traumatic event may be CSF, which can indicate a skull fracture and damage to the meninges. Collecting the fluid on a sterile gauze pad can help confirm the presence of CSF.
C. Suctioning the nose with a bulb syringe is not recommended because it can introduce contaminants into the nasal passages and potentially worsen the injury.
D. Obtaining a culture of the specimen using sterile swabs is a consideration once the presence of CSF is confirmed. However, the initial priority is to identify and collect the clear fluid drainage.
Correct Answer is C
Explanation
A. Mild erythema (redness) at the pin sites can be a normal finding due to the body's response to the presence of foreign objects. It may not necessarily indicate infection.
B. Serosanguineous drainage (a mixture of clear and bloody fluid) can also be a normal finding initially after the insertion of pins. It may not necessarily indicate infection.
C. Fever is a systemic response to infection. In a client with skeletal traction, fever can be an indication of an infection at the pin sites or a more systemic infection related to the traction device.
D. Warmth around the pin sites can be a normal finding due to the inflammatory response that occurs after pin insertion. It may not necessarily indicate infection.
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