Which of the following statements, if made by the client, indicate to the nurse that teaching
regarding home therapy for a severe left ankle sprain has been successful?
A. "I'll gently rotate the left ankle, use intermittent compression on it, and exercise it slowly."
B. "I'll plan to keep my left ankle resting on two pillows, use an ace bandage around it, and
ice my ankle."
C. "I'll use RICES: regulate my pain medication, keep ice on the ankle at all times, contract
and relax my toes, and evenly space walking requirements."
D. "I'll make regular observations of my ankle bruising, indicate on a notepad when I apply
weight to my ankle, clean the skin daily, and empty the icepack when the ice melts." - ANSB.
"I'll plan to keep my left ankle resting on two pillows, use an ace bandage around it, and ice
my ankle."
RICE serves as an acronym to indicate to the client the treatment plan of resting the ankle
(no rotation, exercise, walking or weight bearing during the initial treatment phase); applying
ice (to cause vasoconstriction and reduce pain); use a compression appliance, such as an
ace bandage (to decrease edema formation and pain); and, elevate the injured extremity on
pillows (to decrease edema and pain).
A healthy, active 73 year old client who suffered a fracture of the fibula has suffered a
severely sprained right ankle and is preparing to leave the Emergency Department. Which of
the following aids to ambulation would be most appropriate for the client?
A. Wheel chair
B. Crutches
C. Walker
D. Cane - ANSA. Wheel chair
Older clients will usually find a walker best suited to their needs. With aging, muscle mass in
the upper extremities declines, making crutch walking problematic. The client may eventually
be able to use a cane, but not during the initial post-injury phase. A wheel chair would be
considered if the client were frail or had impaired ambulation skill.
The aged client fell from a bench to the floor and dislocated the right shoulder. The client is
admitted to the hospital overnight. The flow sheet indicated that 10 p.m. neurovascular
check of the right upper extremity was within normal limits. The nurse makes rounds at
midnight, and makes the gathers the following data: right upper extremity pale; unable to
move the lower arm; absent radial and antecubital pulses; and, client's description of "terrible
pain" in the right shoulder and arm. The nurse's first response is to:
A. contact the physician.
, B. recheck the findings in one hour.
C. reposition the extremity and reapply ice to the shoulder.
D. administer pain medication. - ANSA. contact the physician.
The data the nurse has gathered indicates that the client's neurovascular status has
deteriorated and that tissue death may occur if intervention is not taken. The nurse should
contact the physician, report the findings, and document the problem, action taken, and
client response to intervention as prescribed by the physician.
The 64 year old male client dislocated the left shoulder while playing tennis. The client tells
the Emergency Department nurse that the client has dislocated the shoulder several times,
but is usually able to return to tennis within two weeks. The nurse's best response to the
client is that
A. "Prolonged immobilization for several weeks followed by aggressive therapy can reduce
the risk of recurrent dislocation."
B. "Wearing a shoulder brace can prevent dislocation."
C. "Once a shoulder has been dislocated, there is no effective treatment."
D. "Perhaps it's time that you considered participation in a different sport." - ANSA.
"Prolonged immobilization for several weeks followed by aggressive therapy can reduce the
risk of recurrent dislocation."
The nurse's best response is to indicate that prolonged immobilization followed by
aggressive therapy can reduce the risk of recurrence. A shoulder brace limits shoulder
motion and would preclude effective tennis performance. The nurse has no basis for
advising the client to give up tennis. To indicate that there is no effective treatment is
inaccurate.
When the client who has suffered a fractured vertebrae at L5 tells the nurse that the client
has "heard" that fractured vertebrae never really heals, the nurse's best response is that:
A. "Your information is accurate."
B. "Actually, a fractured vertebra usually heals in 6 to 8 weeks."
C. "A fractured vertebra will take at least 12 weeks to heal."
D. "You should ask your doctor about that." - ANSC. "A fractured vertebra will take at least
12 weeks to heal."
One of the nurse's functions is to teach client's about the body and its activities. The nurse
should respond to the client that a fractured vertebra will take at least 12 weeks to heal. An
uncomplicated fracture of the arm or foot can heal in 6 to 8 weeks. To indicate that the
client's hearsay is accurate is incorrect, and to inform the client to ask the physician may
produce unnecessary psychological stress on the client regarding the client's vertebral
healing.
The client who has suffered a fractured left femur in a motor vehicle accident awakens on
the client's first postoperative day since rod placement and indicates to the nurse that the
client's pain is an 11 on a scale of 1 to 10. The nurse palpates the client's left pedal and
ankle pulses. Which of the following actions should the nurse take first?
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