A nurse in an urgent care centre is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)
Apply a compression bandage to the client's ankle.
Apply heat to the client's ankle.
Encourage range of motion of the client's foot.
Elevate the client's foot.
Check the client's toes for color, temperature, and sensation.
Correct Answer : A,D,E
These are the correct interventions that the nurse should take. Applying a compression bandage to the client's ankle can help reduce swelling and provide support to the injured area. Elevating the client's foot can also help reduce swelling by promoting venous return. Checking the client's toes for color, temperature, and sensation is important to assess for any potential nerve or vascular damage.
Applying heat to the client's ankle is not recommended as it can increase swelling and inflammation. Encouraging range of motion of the client's foot is also not recommended as it can cause further injury to the affected area.
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Related Questions
Correct Answer is A
Explanation
The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.
Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, and assisting the client back into bed and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.
Correct Answer is D
Explanation
a. Decorticate posturing is marked by the flexion of the arms, with the hands clenched into fists and the legs extended and internally rotated.
b. External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight.
c.Pronation of the hands is characteristic of decerebrate posturing, where the arms are extended and pronated.
d. In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.
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