A patient is in the ED after falling off a ladder. His ankle appears swollen, out of alignment, and is painful to touch. What will the nurse do first?
Splint and immobilize the extremity
Apply an ice pack to the ankle
Encourage weight bearing and ambulation
Assess pulse, color, temperature and capillary refill
The Correct Answer is D
A) Splint and immobilize the extremity: While immobilizing the injured extremity is important to prevent further injury, it should follow an initial assessment of blood flow and nerve function to ensure there are no vascular or neurological compromises.
B) Apply an ice pack to the ankle: Applying ice can help reduce swelling and alleviate pain. However, it is essential first to assess the circulation to the limb to ensure that applying ice will not worsen any underlying issues.
C) Encourage weight bearing and ambulation: Encouraging weight bearing on a potentially injured ankle can lead to further damage and is not appropriate. The priority is to assess the injury and understand its severity.
D) Assess pulse, color, temperature, and capillary refill: This step is crucial as it evaluates the vascular status of the limb. Assessing these factors helps identify any potential complications, such as compartment syndrome or inadequate blood flow, and guides further management of the injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Avoid hand and foot massages: This statement may not be accurate. Gentle massages can sometimes help with circulation and comfort for individuals with peripheral neuropathy. However, caution should be exercised to avoid injury, as the sensation may be diminished.
B) Use a mirror to inspect feet daily: This is an essential teaching point. Clients with peripheral neuropathy often have decreased sensation in their feet, making it difficult to notice injuries or sores. Using a mirror allows them to check for any signs of injury or changes that could lead to complications, such as infections or ulcers.
C) Increase medication for pain as necessary: While managing pain is important, the client should be advised to consult with their healthcare provider before making any changes to their medication regimen. Self-adjusting medication could lead to unintended side effects or complications.
D) Set the water heater at 120°F: This is not advisable for someone with peripheral neuropathy, as they may not have normal temperature sensation. A lower setting is recommended to prevent burns, as the individual may not feel when the water is too hot.
Correct Answer is C
Explanation
A) Anterior to the elbow: This term describes a location in front of the elbow. While it indicates a direction, it does not specifically address the vertical relationship of the discomfort in relation to the elbow. Since the client described discomfort "above" the elbow, this term is not the most accurate choice.
B) Distal to the elbow: The term "distal" refers to a location that is farther away from the trunk of the body or point of reference. Given that the discomfort is described as being above the elbow, this term is incorrect, as it would imply the discomfort is located toward the hand rather than toward the shoulder.
C) Proximal to the elbow: This term correctly indicates a location closer to the trunk of the body and specifically suggests that the discomfort is situated above the elbow, making it the most appropriate medical terminology to use in this context. It accurately reflects the relationship of the discomfort to the elbow.
D) Inferior to the elbow: "Inferior" refers to a location below another point of reference. Since the discomfort is described as above the elbow, this terminology would not apply and would misrepresent the location of the client’s discomfort.
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