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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View 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 B
Explanation
A) To determine the location of the pain: While knowing the location of the pain can be relevant for overall assessment, this is not the main reason for reassessing pain after treatment. The focus is more on understanding the response to treatment rather than just identifying where the pain is.
B) To establish the effectiveness of medication: Reassessing pain after treatment is essential to evaluate how well the medication has alleviated the pain. This helps the nurse determine if the current pain management approach is effective or if modifications are necessary to improve the patient's comfort.
C) To make changes to the patient's pain goal: While understanding pain levels can inform care planning, the primary purpose of reassessing pain is to gauge treatment effectiveness rather than directly changing the pain management goals at that moment.
D) To measure the pain's duration: Measuring the duration of pain may be useful in a broader context of pain management, but it is not the immediate rationale for reassessing pain after treatment. The focus should be on the effectiveness of the intervention rather than just how long the pain lasts.