A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

Ask the patient to try bearing weight on the ankle

Elevate the ankle above heart level

Apply a warm moist pack to the ankle

Assess the ankle's passive range of motion (ROM)

Answer and Explanation

The Correct Answer is B

Choice A reason: Asking the patient to try bearing weight on the injured ankle is not appropriate at this stage. Bearing weight can cause further injury or exacerbate the swelling and pain. The initial treatment should focus on reducing swelling and providing support.

Choice B reason: Elevating the ankle above heart level is appropriate because it helps to reduce swelling by promoting venous return and decreasing fluid accumulation in the affected area. Elevation is a standard first aid measure for managing acute injuries and swelling.

Choice C reason: Applying a warm moist pack to the ankle is not advisable immediately after an injury. In the acute phase, cold therapy (ice) is recommended to reduce swelling and pain. Warm therapy is more appropriate during the recovery phase, once swelling has subsided.

Choice D reason: Assessing the ankle's passive range of motion (ROM) may be necessary later, but not immediately upon arrival. The priority is to manage pain and swelling first. ROM assessments can be painful and might worsen the injury if conducted too soon.

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Correct Answer is C

Explanation

Choice A reason: Fluid volume overload is not typically associated with diabetes insipidus. Instead, patients with diabetes insipidus often experience fluid volume deficit due to excessive urine output.

Choice B reason: Hyperglycemia is not a characteristic problem of diabetes insipidus. This condition involves an imbalance in water regulation due to insufficient production or response to antidiuretic hormone (ADH), rather than issues related to blood glucose levels.

Choice C reason: Nocturia, or frequent urination at night, is a common problem in diabetes insipidus. Patients with this condition produce large amounts of dilute urine, which can lead to frequent nighttime urination.

Choice D reason: Generalized edema is not a typical problem in diabetes insipidus. Edema is more commonly associated with conditions involving fluid retention, such as heart failure or kidney disease, rather than the excessive fluid loss seen in diabetes insipidus.

A. Oxygen mask B. Nasogastric tube C. Urinary catheter D. Suction set-up E. Tongue blade F. Side rail pads

Correct Answer is ["A","D","F"]

Explanation

Choice A reason: An oxygen mask is essential for providing supplemental oxygen to the patient, especially if they experience respiratory distress or decreased oxygen saturation following a seizure. Ensuring adequate oxygenation is a priority in post-seizure care.

Choice B reason: A nasogastric tube may be used in specific situations for feeding or medication administration, but it is not routinely necessary for all patients treated for status epilepticus.

Choice C reason: A urinary catheter is used for managing urinary output, particularly in patients with retention or incontinence issues, but it is not immediately required for all patients post-status epilepticus.

Choice D reason: Suction set-up is necessary for maintaining the patient's airway and preventing aspiration, particularly if the patient has excessive secretions or vomits after a seizure. Suction equipment allows the nurse to quickly clear the airway and ensure the patient can breathe effectively.

Choice E reason: Tongue blades are not recommended for seizure management as they can cause injury. Historically, there was a misconception about using tongue blades to prevent tongue biting during seizures, but this practice is now discouraged due to the risk of oral injury.

Choice F reason: Side rail pads are important for protecting the patient from injury during potential future seizures. Padded side rails help prevent trauma from hitting the bed rails during convulsions and provide a safer environment for the patient.

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A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus?

Correct Answer is C

Explanation

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply)

Correct Answer is ["A","D","F"]

Explanation

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