A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?
“I’ll apply ice to my ankle for 20 minutes every hour.”
“I’ll rewrap my ankle starting from the knee down.”
“I’ll walk on my ankle for 10 minutes every hour.”
“I’ll put a heating pad on my ankle at bedtime tonight.”
The Correct Answer is A
A. "I’ll apply ice to my ankle for 20 minutes every hour."
This is the correct choice. Applying ice for a specified duration (20 minutes) every hour is a standard recommendation for managing swelling and pain associated with an ankle sprain. It helps reduce inflammation and provides relief.
B. "I’ll rewrap my ankle starting from the knee down."
This statement indicates a misunderstanding. When rewrapping an ankle, it should be done from the bottom (proximal) to the top (distal) to provide proper compression. Starting from the knee down is not the correct technique.
C. "I’ll walk on my ankle for 10 minutes every hour."
This statement may indicate a misunderstanding or potential for harm. Immediate weight-bearing or walking on an injured ankle, especially after a sprain, is generally not recommended. Rest is often a key component of initial management.
D. "I’ll put a heating pad on my ankle at bedtime tonight."
This statement may indicate a misunderstanding. Heat is not typically recommended in the initial stages of treating an acute injury like an ankle sprain, as it may increase inflammation. Ice (cold therapy) is usually the preferred modality early on to reduce swelling and pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Rub the client’s feet briskly for several minutes.
Rubbing the feet briskly may not be appropriate for a client with vascular occlusion. Vigorous rubbing could potentially cause damage to already compromised blood vessels, and the increased friction may not be well-tolerated.
B. Obtain a pair of slipper socks for the client.
Providing slipper socks is a non-invasive and appropriate measure to help keep the client's feet warm. Slipper socks can offer comfort without the need for vigorous interventions or potential harm. They provide insulation and can be easily applied.
C. Increase the client’s oral fluid intake.
While staying well-hydrated is generally important for overall health, increasing oral fluid intake may not directly address the specific issue of cold feet associated with vascular occlusion. It is essential to address the underlying circulatory issue causing the symptom.
D. Place a moist heating pad under the client’s feet.
Applying heat, especially in the form of a moist heating pad, may not be recommended for a client with vascular occlusion. Heat can dilate blood vessels and potentially exacerbate the issue by increasing blood flow to the compromised extremity. It's important to avoid interventions that could worsen the vascular compromise.
Correct Answer is B
Explanation
A. Electrolyte imbalances
Administering diluted enteral feedings is not typically done to address electrolyte imbalances. Instead, monitoring the electrolyte levels in the patient's blood and adjusting the content of the enteral formula (such as adjusting the concentration of electrolytes) would be more appropriate.
B. Diarrhea
Administering diluted enteral feedings is a strategy that may be employed to prevent or manage diarrhea. High concentrations of nutrients can overwhelm the gastrointestinal tract, leading to diarrhea. Diluting the formula helps reduce the risk of this complication.
C. Constipation
Administering diluted enteral feedings is not typically done to address constipation. Management of constipation is more commonly achieved through adjustments in fiber intake, fluid intake, and medications as needed.
D. Delayed gastric emptying
Administering diluted enteral feedings is not a standard approach for addressing delayed gastric emptying. Instead, adjustments in the rate of enteral feedings or specific interventions for delayed gastric emptying, such as medication or changes in positioning, would be considered.
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