A nurse is caring for a client who has an acute ankle sprain.Which of the following actions should the nurse take? (Select all that apply.)

Choice A rationale

Polyuria is defined as excessive or abnormally large production or passage of urine, often greater than 2.5 liters in a 24-hour period. It is typically associated with conditions like diabetes mellitus (osmotic diuresis) or diabetes insipidus (deficiency of antidiuretic hormone). A routine urinary tract infection (UTI) usually presents with symptoms like increased frequency and urgency, but not necessarily an increase in total urine volume.

Choice B rationale

Urinary frequency is a classic symptom of a urinary tract infection (UTI), particularly cystitis (bladder infection). Inflammation and irritation of the bladder lining (urothelium) caused by the colonizing bacteria (often E. coli) lead to increased sensitivity and involuntary detrusor muscle contractions, resulting in a persistent, urgent, and frequent need to void small amounts of urine.

Choice C rationale

Dysuria, or painful and difficult urination, is a hallmark clinical manifestation of a urinary tract infection (UTI). The discomfort arises from the inflammatory response in the urethra and bladder lining (mucosa) as the body attempts to fight the bacterial invasion, causing a burning sensation, especially upon the passage of acidic urine over the inflamed tissues.

Choice D rationale

Dependent edema is the accumulation of excess interstitial fluid in the body's lower extremities due to the effect of gravity, often associated with systemic conditions like heart failure (elevated venous pressure) or renal disease (proteinuria/hypoalbuminemia). It is not a typical or expected finding directly associated with an uncomplicated, localized urinary tract infection (UTI).

Choice E rationale

Hematuria, the presence of blood in the urine, is a common finding in urinary tract infections (UTIs), especially cystitis. Inflammation and damage to the delicate capillary walls and mucosal lining of the bladder and lower urinary tract by the invading bacteria (e.g., E. coli) and the host's immune response can lead to the leakage of red blood cells into the urine.

Choice A rationale

Monitoring the White Blood Cell (WBC) count is primarily a measure for detecting and tracking infection (normal range 4,500–11,000 cells/mm) or inflammatory processes, not a direct preventative action for deep vein thrombophlebitis (DVT). While inflammation can contribute to hypercoagulability, this action doesn't mechanically or chemically prevent venous stasis or hypercoagulability, the Virchow's triad components.

Choice B rationale

Encouraging increased fluid intake helps to maintain adequate intravascular volume and reduce blood viscosity. Hemoconcentration, resulting from dehydration, increases the concentration of clotting factors and blood cells, making the blood more viscous and sluggish, thus promoting venous stasis and increasing the risk of DVT formation.

Choice C rationale

Keeping the affected knee flexed can compress the popliteal vein, a major deep vein, especially when maintained for prolonged periods post-operatively. This compression promotes venous stasis distal to the flexion point, which is a critical component of Virchow's triad and significantly increases the risk for deep vein thrombophlebitis development.

Choice D rationale

Prolonged bed rest, especially beyond 24-48 hours without prophylactic measures, dramatically reduces the activity of the skeletal muscle pump in the lower extremities. This lack of muscle contraction and relaxation greatly impairs venous return to the heart, leading to severe venous stasis and a high risk of deep vein thrombophlebitis.