A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?
"I will apply heat to my affected ankle to decrease swelling."
"I can bear full weight on my affected ankle."
"I can dangle my affected ankle from the edge of the bed."
"I will wrap my affected ankle with an elastic bandage."
The Correct Answer is D
Choice A Reason:
"I will apply heat to my affected ankle to decrease swelling." Heat application is generally not recommended for acute injuries like ankle sprains. Heat can increase blood flow and potentially worsen swelling. Cold therapy (like ice) is typically advised in the early stages to reduce inflammation and swelling.
Choice B Reason:
"I can bear full weight on my affected ankle." For a grade 2 ankle sprain, bearing full weight on the affected ankle might not be advisable initially. Grade 2 sprains involve partial tearing of ligaments and usually require some period of rest or limited weight-bearing to allow healing.
Choice C Reason:
"I can dangle my affected ankle from the edge of the bed. “Dangling the affected ankle from the edge of the bed is a common recommendation to help with gentle movement and improve blood flow without putting excessive stress on the injured ankle. This activity can aid in the recovery process and is often recommended.
Choice D Reason:
"I will wrap my affected ankle with an elastic bandage. “Wrapping the affected ankle with an elastic bandage is a supportive measure recommended for managing ankle sprains. It helps provide compression, support, and stabilization to the injured area, assisting in reducing swelling and providing comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"I will perform breast exams the day my period begins." This statement is incorrect because performing breast exams just before or during your period might not be ideal. Breasts can be more tender or swollen during this time, which could make it harder to detect any abnormalities.
Choice B Reason:
"I will perform breast exams every other month." This statement is incorrect. Regular breast self-exams are important, but doing them every other month might not be frequent enough. It's generally recommended to perform breast self-exams once a month, ideally around the same time each month, to detect any changes or abnormalities early.
Choice C Reason:
"It is common for the skin on my breasts to dimple." This statement is incorrect. Dimpling or puckering of the skin on the breasts can sometimes be a sign of an underlying issue, such as breast cancer. It's not considered a normal or common occurrence, so this statement doesn't indicate an understanding of what to look for during a breast self-exam. If a person notices skin changes like dimpling, it's recommended to seek medical advice.
Choice D Reason:
"It is common for one breast to be larger than the other." This statement reflects an understanding that breast asymmetry, where one breast is slightly larger than the other, is a common and normal occurrence.
Correct Answer is D
Explanation
Choice A Reason:
Jaundice, characterized by yellowing of the skin and eyes, is typically associated with liver dysfunction or conditions affecting the breakdown of red blood cells, not directly linked to Cushing's syndrome. While some liver abnormalities can be seen in Cushing's syndrome due to metabolic changes, jaundice is not a typical manifestation of this condition.
Choice B Reason:
Muscle rigidity is more commonly associated with conditions like Parkinson's disease, dystonia, or certain muscle disorders. In Cushing's syndrome, muscle weakness due to protein breakdown and muscle wasting is a more expected finding rather than muscle rigidity.
Choice C Reason:
Weight loss is incorrect. Weight gain, particularly in the central part of the body (trunk) and face (creating a "moon face"), is a more common characteristic of Cushing's syndrome. The excess cortisol often leads to increased fat deposits, especially in these areas, rather than weight loss.
Cushing's syndrome is characterized by an excess of cortisol in the body, either due to the body producing too much cortisol or from long-term use of corticosteroid medications. Considering this condition, the nurse should expect the following finding:
Choice D Reason:
Easily bruised is correct. Excess cortisol can lead to the thinning of the skin and weakening of blood vessels, making individuals with Cushing's syndrome prone to easy bruising. Other common findings associated with Cushing's syndrome include weight gain (especially in the trunk and face), muscle weakness, high blood pressure, fatigue, and changes in skin such as thinning and purple stretch marks.

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