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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Instructing the client on the use of crutches is important but not the most crucial immediately postoperatively. Ensuring the client's neurovascular status is stable takes priority.

B. Directing the client to perform ankle and toe exercises is important for preventing complications like deep vein thrombosis (DVT) and maintaining joint mobility. However, it is not the most critical action in the immediate postoperative period.

C. Medicating the client for pain is essential for comfort and recovery, but it should be based on a pain assessment and should not take precedence over assessing neurovascular status.

D. Performing neurovascular checks of the extremities is the most crucial action in the postoperative period after orthopedic surgery. It helps to ensure there is adequate blood flow and nerve function to the affected limb, which is essential for preventing complications such as compartment syndrome or vascular compromise.

A. Delaying the surgery until a member of the client's family is reached B. Prescribing naloxone to reverse the effects of the morphine C. Invoking implied consent D. Asking the client to sign the surgical consent form

Correct Answer is C

Explanation

A. Delaying the surgery until a member of the client's family is reached may not be in the best interest of the client if urgent surgical intervention is indicated.

B. While naloxone can reverse the effects of opioids like morphine, it is not the primary action the neurosurgeon would take in this situation. The priority is addressing the urgent surgical need.

C. Invoking implied consent is the most appropriate action in this situation. Implied consent is assumed in emergency situations where the client is unable to provide consent, and delay would significantly jeopardize the client's health.

D. Asking the client to sign the surgical consent form would not be feasible in this situation since the client is likely not in a condition to provide informed consent due to the administration of intravenous morphine and the urgency of the surgical intervention.

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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?

Nursing Test Bank

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