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 D
Explanation
A. Peripheral Artery Disease (PAD). PAD is a chronic condition related to reduced blood flow in peripheral arteries. It is not directly associated with MI complications.
B. Gastroesophageal Reflux Disease (GERD). GERD involves acid reflux and is not related to post-MI complications.
C. Hypertension. While hypertension is a risk factor for MI, it does not directly explain the symptoms of shortness of breath and irregular heartbeats following an MI.
D. Heart Failure. Heart failure is a common post-MI complication, especially if a significant portion of heart muscle is damaged. Symptoms of shortness of breath and irregular heartbeats could indicate left-sided heart failure, where fluid backs up into the lungs, or right-sided failure, which can lead to systemic congestion.
Correct Answer is D
Explanation
A. Pain in the neck when the patient flexes their head towards the chest. This describes nuchal rigidity, not Kernig sign.
B. Involuntary flexion of the hips and knees when the neck is flexed. This describes Brudzinski sign, not Kernig sign.
C. Photophobia and headache triggered by bright light. These are symptoms of meningitis, but they are not specific to Kernig sign.
D. Pain and resistance when attempting to extend the patient's leg from a flexed position. A positive Kernig sign is when there is pain and resistance to leg extension from a flexed hip and knee position, indicating meningeal irritation.