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
Explanation
Choice A reason: Hypothermia
Hypothermia, or abnormally low body temperature, is not a typical manifestation of acute osteomyelitis. Osteomyelitis usually presents with signs of infection, such as fever, rather than a drop in body temperature. Therefore, hypothermia is not a relevant symptom in this context.
Choice B reason: Localized edema
Localized edema, or swelling, is a common symptom of acute osteomyelitis. The infection in the bone can cause inflammation and swelling in the surrounding tissues. This is often accompanied by warmth and redness over the affected area. Therefore, localized edema is a key manifestation of acute osteomyelitis.
Choice C reason: Numbness of toes on the affected foot
Numbness of the toes is not a typical symptom of acute osteomyelitis. While nerve involvement can occur in severe cases, it is not a primary manifestation. Acute osteomyelitis primarily presents with signs of infection and inflammation, such as pain, swelling, and redness.
Choice D reason: Bradycardia
Bradycardia, or a slow heart rate, is not associated with acute osteomyelitis. The condition typically presents with systemic signs of infection, such as fever and malaise, rather than changes in heart rate. Bradycardia is more commonly related to cardiac conditions or certain medications.
Correct Answer is B
Explanation
Choice A reason: Sometimes my child acts bossy with his friends is a common behavior in children as they navigate social interactions and develop leadership skills. While it may require some guidance on social skills, it is not typically a cause for medical concern.
Choice B reason: The teacher says my child has to squint to see the board is concerning because it indicates a potential vision problem. Squinting to see the board can be a sign of refractive errors such as myopia (nearsightedness) or astigmatism. Early detection and correction of vision problems are crucial for a child’s academic performance and overall development.
Choice C reason: My child has recently lost both front top teeth is a normal part of dental development. Children typically lose their primary (baby) teeth around the age of 6 to 7 years as their permanent teeth begin to erupt. This is a natural process and not a cause for concern.
Choice D reason: My child often cheats when we play board games can be a normal part of a child’s development as they learn about rules and fairness. While it may require parental guidance to teach honesty and fair play, it is not typically a medical concern.
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