A nurse is teaching a client who has a new second-degree ankle sprain. Which of the following instructions should the nurse include in the teaching? Select all that apply.
Apply intermittent ice to the affected ankle for the first 48 hours.
Wrap the affected ankle with an elasticized compression bandage.
Apply full weight-bearing on the affected ankle.
Elevate the affected ankle above the level of the heart.
Apply a heating pad intermittently to the affected ankle after 48 hours.
Correct Answer : A,B,D,E
Choice A reason: Apply intermittent ice to the affected ankle for the first 48 hours
Applying ice intermittently to the affected ankle for the first 48 hours helps reduce swelling and inflammation. Ice should be applied for 15-20 minutes every 2-3 hours during the initial phase of injury management. This practice is part of the RICE (Rest, Ice, Compression, Elevation) protocol commonly used for sprains and strains.
Choice B reason: Wrap the affected ankle with an elasticized compression bandage
Wrapping the affected ankle with an elasticized compression bandage helps to minimize swelling and provide support to the injured area. Compression bandages should be snug but not too tight to avoid restricting blood flow. This is another component of the RICE protocol.
Choice C reason: Apply full weight-bearing on the affected ankle
Applying full weight-bearing on the affected ankle is not recommended immediately after a second-degree sprain. The ankle needs time to heal, and weight-bearing should be gradually reintroduced as pain and swelling decrease. Initially, the client should avoid putting weight on the injured ankle to prevent further damage.
Choice D reason: Elevate the affected ankle above the level of the heart
Elevating the affected ankle above the level of the heart helps reduce swelling by promoting venous return and decreasing fluid accumulation in the injured area. This is an essential part of the RICE protocol and should be done as much as possible during the first 48 hours.
Choice E reason: Apply a heating pad intermittently to the affected ankle after 48 hours
Applying a heating pad intermittently to the affected ankle after 48 hours can help increase blood flow and promote healing. Heat therapy should be used after the initial acute phase (first 48 hours) when swelling has subsided. Heat can help relax muscles and reduce stiffness in the injured area.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A reason:
The statement “Long attention span” is generally not associated with autism spectrum disorder (ASD). Children with ASD often have difficulty maintaining attention on tasks or activities, especially those that do not interest them. They may exhibit hyperfocus on specific interests but typically struggle with sustained attention in other areas.
Choice B reason:
The statement “Delayed language development” is a common characteristic of ASD. Many children with autism experience delays in speech and language skills. They may have difficulty with verbal communication, understanding language, and using language in social contexts. This delay can vary widely among individuals with ASD.
Choice C reason:
The statement “Speaking with direct eye contact” is not typically associated with ASD. Children with autism often avoid direct eye contact and may find it uncomfortable or overwhelming. They might look away or use peripheral vision instead of making direct eye contact during conversations.
Choice D reason:
The statement “Repetitive behavior” is a hallmark of ASD. Children with autism often engage in repetitive behaviors, such as hand-flapping, rocking, or repeating certain actions or phrases. These behaviors can be a way to self-soothe or cope with sensory overload.
Choice E reason:
The statement “Playing with toys repetitively” is also characteristic of ASD. Children with autism may play with toys in a repetitive manner, such as lining them up, spinning them, or focusing on specific parts of the toy rather than using them in imaginative play. This repetitive play is part of the broader pattern of repetitive behaviors seen in ASD.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: The preschooler mispronounces words can be a sign of a speech sound disorder. While some mispronunciation is normal in early speech development, persistent difficulty with articulation may indicate a need for speech therapy to improve clarity and communication skills.
Choice B reason: The preschooler speaks in three-word sentences may indicate a delay in expressive language development. By preschool age, children typically use longer sentences and more complex language structures. Limited sentence length can suggest a need for further evaluation and intervention.
Choice C reason: The preschooler stutters when speaking can be a sign of a fluency disorder. Stuttering involves disruptions in the flow of speech, such as repetitions, prolongations, or blocks. Early intervention with speech therapy can help manage and reduce stuttering.
Choice D reason: The preschooler talks to himself when reading is generally not a concern. Self-talk can be a normal part of development and learning, as children often verbalize their thoughts and actions. It does not typically indicate a need for speech therapy.
Choice E reason: The preschooler speaks in a nasally tone can indicate a resonance disorder, which affects the quality of the voice. A nasally tone may result from structural issues or improper use of the vocal tract. Speech therapy can help address these issues and improve vocal quality.
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