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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Hyperlipidemia
Hyperlipidemia, or high levels of lipids in the blood, can be a contributing factor to acute pancreatitis. Elevated triglycerides can lead to the development of pancreatitis, especially when levels exceed 1000 mg/dL. However, it is less common compared to gallstones and alcohol abuse as a cause of acute pancreatitis.
Choice B reason: Gallstones
Gallstones are one of the most common causes of acute pancreatitis. They can block the bile duct, leading to a buildup of pancreatic enzymes and subsequent inflammation of the pancreas. This condition, known as gallstone pancreatitis, accounts for a significant percentage of acute pancreatitis cases. Therefore, it is crucial for the nurse to inquire about a history of gallstones when assessing a client with acute pancreatitis.
Choice C reason: COPD
Chronic Obstructive Pulmonary Disease (COPD) is not directly related to the development of acute pancreatitis. While COPD is a significant chronic condition that affects the lungs, it does not have a known association with pancreatitis. Therefore, this factor is less relevant in the context of acute pancreatitis.
Choice D reason: Diabetes mellitus
Diabetes mellitus can be both a consequence and a risk factor for pancreatitis. Chronic pancreatitis can lead to diabetes due to the damage to insulin-producing cells in the pancreas. However, diabetes itself is not a common cause of acute pancreatitis. It is more relevant in the context of chronic pancreatitis and its complications.
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.
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