A client presents the emergency department with a Grade II ankle sprain. Which of the following interventions should the nurse implement?
Encourage the client to walk on the injured ankle to promote circulation.
Immerse the ankle in want water immediately after the in
Apply ice to the affected ankle for the first 24-72 hours.
Perform deep tissue massage on the injured area to reduce pain.
The Correct Answer is C
A. Encourage the client to walk on the injured ankle to promote circulation. Weight-bearing activities should be avoided initially after a Grade II sprain to prevent further injury.
B. Immerse the ankle in warm water immediately after the injury. Ice, rather than warmth, is recommended immediately following an injury to reduce swelling and inflammation.
C. Apply ice to the affected ankle for the first 24-72 hours. Applying ice for 24-72 hours helps reduce swelling and pain by causing vasoconstriction and controlling inflammation in the acute phase.
D. Perform deep tissue massage on the injured area to reduce pain. Massaging a newly sprained ankle can aggravate inflammation and cause additional tissue damage.
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Correct Answer is C
Explanation
A. Administering pain medication: Pain management is essential, but in this case, the primary concern is potential airway compromise due to inhalation injury, which should be addressed first.
B. Applying a cool, wet cloth to burned areas: Cooling burned areas can help with pain and reduce burn severity but is not the priority in a case of suspected inhalation injury with airway compromise.
C. Administering high-flow oxygen via a non-rebreather mask: This client is at high risk for respiratory compromise due to inhalation injury; administering high-flow oxygen is the priority to ensure adequate oxygenation.
D. Initiating intravenous fluid resuscitation: Fluid resuscitation is essential for burn patients but is not the immediate priority over addressing potential airway and oxygenation issues.
Correct Answer is B
Explanation
A. Inflammation of the motor cortex leads to decreased coordination and balance. Parkinson’s disease is not caused by inflammation in the motor cortex; it primarily involves the loss of dopamine-producing neurons.
B. Degeneration of dopamine-producing neurons in the substantia nigra of the brain leads to motor dysfunction. Parkinson’s disease is caused by the degeneration of dopamine-producing neurons in the substantia nigra, leading to motor symptoms such as tremors, rigidity, and bradykinesia.
C. A loss of acetylcholine in the brain leads to memory problems and cognitive decline. While a loss of acetylcholine is associated with Alzheimer’s disease, it is not the primary issue in Parkinson’s disease.
D. Excess production of dopamine in the basal ganglia leads to tremors and muscle rigidity. In Parkinson’s disease, there is a decrease, not an excess, in dopamine production, which contributes to motor symptoms.