A nurse is caring for a school-age child who sprained their ankle 1 hr ago. Which of the following actions should the nurse take to decrease the swelling?
Wrap the ankle with an elastic bandage.
Encourage active exercise of the ankle.
Place the ankle below the level of the heart.
Apply ice packs directly to the ankle in 60 min intervals.
The Correct Answer is A
A. Wrap the ankle with an elastic bandage: Applying an elastic bandage provides compression, which helps reduce swelling by limiting fluid accumulation in the injured tissues. Compression also supports the ankle and helps prevent further injury.
B. Encourage active exercise of the ankle: Active exercise immediately after a sprain can increase swelling and worsen the injury. Rest and immobilization are essential in the initial phase to promote healing and minimize inflammation.
C. Place the ankle below the level of the heart: Positioning the ankle below heart level promotes blood pooling and increases swelling. Elevation above heart level is recommended to help reduce edema.
D. Apply ice packs directly to the ankle in 60 min intervals: Ice helps reduce swelling and pain, but applying ice directly to the skin can cause tissue damage. Ice packs should be wrapped in a cloth and applied intermittently (usually 15–20 minutes on, then off) to avoid frostbite and skin injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
Rationale for Correct Answers:
- Hydrocephalus: Inflammation of the meninges can block cerebrospinal fluid (CSF) flow, leading to ventricular dilation and hydrocephalus, a known complication of bacterial meningitis.
- Seizures: Meningeal irritation and increased intracranial pressure can cause seizures. Children with altered mental status and fever are at heightened risk.
- Subdural effusions: These may develop due to inflammation and accumulation of fluid between the dura and arachnoid layers, often seen in pediatric meningitis cases.
- Hearing loss: Sensorineural hearing loss may result from inflammation or damage to the auditory nerve or cochlea. It’s a well-documented sequela of meningitis.
Rationale for Incorrect Choices:
- Laryngospasm: Typically associated with airway irritation or hypocalcemia, not a common or expected complication of meningitis.
- Demyelination: More commonly linked to conditions like multiple sclerosis. Meningitis does not typically cause demyelination of neurons.
- Guillain-Barré syndrome: An autoimmune condition often triggered by viral illness, not by meningitis. It involves peripheral nervous system demyelination, unrelated to this case.
Correct Answer is A
Explanation
A. Offer 1 tablespoon as a serving size for the infant's solid food: A typical serving size for solid foods when starting infants around 4 to 6 months is about 1 tablespoon per feeding, which helps avoid overfeeding and allows gradual introduction of solids.
B. Introduce solid foods when the infant reaches 3 months of age: Introducing solids before 6 months is not recommended due to immature digestive systems and increased risk of choking and allergies.
C. Add 1 teaspoon of honey to the infant's bottle of formula if constipation occurs: Honey should never be given to infants under 1 year old due to the risk of infant botulism, a serious and potentially fatal illness.
D. Introduce the infant to a new solid food every other day: Current recommendations suggest introducing one new food every 4 to 7 days to monitor for any allergic reactions or intolerance.
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