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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Barrel Chest: This term describes a condition where the anterior-posterior (AP) diameter of the chest is equal to the transverse diameter, giving the chest a rounded appearance. This finding is often observed in older adults or individuals with chronic respiratory conditions, and it indicates a potential increase in lung volume and air trapping, commonly seen in conditions like emphysema or chronic obstructive pulmonary disease (COPD).

B) Chronic Obstructive Pulmonary Disease: While barrel chest can be associated with COPD, it is not a direct descriptor of the chest shape. COPD encompasses various symptoms and physiological changes but does not specifically define the chest's physical appearance as barrel-shaped.

C) Anterior/Posterior Distortion: This term does not accurately describe the findings observed in the assessment. While it suggests some alteration in chest shape, it does not specifically refer to the characteristic appearance of barrel chest, which is a well-defined clinical term.

D) Lordosis: This refers to an excessive inward curve of the spine, particularly in the lumbar region. While it may affect posture and overall body alignment, it does not relate to the chest shape or measurements, making it an inappropriate choice in this context.

A. Crepitus B. Positive joint sounds C. Grating and popping D. Crackles

Correct Answer is A

Explanation

A) Crepitus: This is the correct term to document the grating sound heard when a joint is moved. Crepitus can indicate issues such as the presence of air in the joint, cartilage degeneration, or other pathologies. Using this specific term provides clarity to the medical record and helps other healthcare providers understand the nature of the joint's condition.

B) Positive joint sounds: This phrase is less specific and does not adequately describe the type of sound noted during the assessment. It may also lead to ambiguity, as it lacks the medical precision that crepitus provides.

C) Grating and popping: While this description conveys what the nurse observed, it is not a standardized medical term. Precise documentation is essential in medical records, and using non-standard language can lead to confusion.

D) Crackles: Typically associated with respiratory assessments, crackles refer to sounds heard in the lungs and are not applicable to joint examinations. Therefore, this term would be inappropriate for documenting findings related to joint movement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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