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 B
Explanation
A. Administer high-calorie diet to prevent weight loss. While adequate nutrition is important, a high-calorie diet is not the primary priority in managing heart failure. Sodium and fluid management are usually more crucial to control fluid overload.
B. Reduce sodium intake to help manage fluid retention. Reducing sodium intake is a priority in heart failure management as it helps prevent fluid retention, which reduces workload on the heart and decreases symptoms of fluid overload.
C. Encourage complete bed rest to reduce cardiac workload. Complete bed rest is not recommended as it can lead to deconditioning and increased risk of blood clots. Activity should be balanced according to the patient’s tolerance.
D. Increase fluid intake to maintain hydration. In heart failure, increasing fluid intake could worsen fluid overload. Fluid restriction may be necessary to prevent excess fluid retention.
Correct Answer is A
Explanation
A. Stroke: The sudden onset of one-sided weakness, numbness, difficulty speaking, and severe headache are classic symptoms of an acute stroke, where blood flow to part of the brain is interrupted, leading to neurological deficits.
B. Migraine: While migraines can cause headache and some neurological symptoms, they usually include visual disturbances, nausea, or photophobia rather than one-sided weakness and numbness.
C. Hypoglycemia: Hypoglycemia can cause confusion, weakness, and headache, but it typically lacks the focal neurological symptoms, like one-sided weakness and numbness.
D. Transient Ischemic Attack (TIA): A TIA can cause similar symptoms, but the deficits are usually transient and resolve within 24 hours without lasting neurological damage. Persistent symptoms are more indicative of a stroke.