A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?

Apply the elastic compression dressing tight enough so the toes and ankle become numb.

Place moderate weight on the aﬀected leg when walking.

Elevate the aﬀected ankle to the level of the heart.

Apply heat during the first 24 hr.

Answer and Explanation

The Correct Answer is C

The nurse should instruct the client to elevate the aﬀected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood ﬂow to the injured area. This is an important part of the RICE (Rest, Ice, Compression, Elevation) method for treating sprains and strains.

a. The elastic compression dressing should not be applied so tight that it causes numbness in the toes and ankle.
b. The client should avoid placing weight on the aﬀected leg when walking until advised by a healthcare provider.
d. Heat should not be applied during the first 24 hours after a sprain as it can increase swelling and inﬂammation.

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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.

A. Apply heat to the area of swelling for the first 48 hr. B. Repeatedly ask the client questions to check for orientation. C. Do not let the client engage in strenuous activities for 1 week. D. Encourage the client to sleep for the first 24 hr.

Correct Answer is C

Explanation

The nurse should instruct the family to not let the client engage in strenuous activities for 1 week following a minor head injury. This can help prevent further injury and allow the client to rest and recover.

Applying heat to the area of swelling for the first 48 hr, repeatedly asking the client questions to check for orientation, and encouraging the client to sleep for the first 24 hr are not appropriate instructions for the nurse to include in this situation. Applying heat can increase swelling and inﬂammation. Repeatedly asking the client questions can be disorienting and confusing. Encouraging the client to sleep for the first 24 hr is not necessary and could interfere with monitoring the client's condition.

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A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?

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