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A client was playing softball and was hit in the right ankle by the ball, sustaining a contusion. What is the first action the nurse takes to help alleviate pain and swelling?
- A. Apply heat to the ankle.
- B. Apply a cold pack to the ankle.
- C. Administer ibuprofen (Advil).
- D. Ask the client to walk to stretch the ligaments.
Correct Answer: B
Rationale: Applying cold packs helps to alleviate local pain, swelling, and bruising. Heat is not used initially after injury, because it can dilate the blood vessels, causing increased bruising and pain. Ibuprofen (Advil) would not be a priority action at this time. The client should not walk on the injured foot or ankle until serious injury is ruled out.
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The nurse is designing a teaching plan for a client with a ruptured Achilles tendon. What education will the nurse provide?
- A. Dietary restrictions
- B. Activity restrictions
- C. Use of nonprescription medications
- D. Effective pin care
Correct Answer: B
Rationale: The nurse should emphasize information about the activity restrictions, the use of ambulatory aids, and pain management to a client with a ruptured Achilles tendon. The client need not be advised about his or her diet or the use of nonprescription medications. Teaching about pin care is also not necessary for such a client because pins are not used to treat a ruptured Achilles tendon.
A client arrives in the emergency department complaining of severe pain in the left hip after falling out of the bed. What indication(s) upon assessment does the nurse recognize as a dislocated left hip?
- A. The left leg appears shorter
- B. The skin is warm to the touch
- C. Limited range of motion of the left hip
- D. Swelling around the hip
- E. The skin of the lower left leg is pale
- F. The client is able to bend the knee but not move toes
Correct Answer: A,C,D
Rationale: The leg may be shorter than its unaffected counterpart as a result of the displacement of one of the articulating bones. Range of motion is limited. Evidence of soft tissue injury includes swelling, coolness, numbness, tingling, and pale or dusky color. The client will not be able to bend the knee easily, and toe movement is typically preserved unless there is nerve damage.
A client is diagnosed with a first-degree strain of the left ankle related to running 5 miles daily. How would the nurse differentiate the first-degree strain from other strains and sprains?
- A. The client has some edema of the left ankle with muscle spasms but is able to walk without assistive devices.
- B. The client is unable to bear weight on the left ankle and has a large ecchymotic area.
- C. The client has ecchymosis, edema, and has no function of the left foot and ankle.
- D. The client complains of pain when the joint is moved and has mild edema.
Correct Answer: A
Rationale: A first-degree strain involves mild stretching of the muscle or tendon, causing some edema and muscle spasm, but no real loss of function. The second-degree strain is partial tearing of muscle or tendon, leading to inability to bear weight and causing edema, muscle tenderness, muscle spasm, and ecchymosis. The third-degree tear is severe muscle and/or tendon tearing, causing severe pain, muscle/spasm ecchymosis, edema, and loss of function. A first-degree sprain involves stretching of the ligament fibers characterized by mild edema, tenderness, and pain if the joint is moved.
A client comes to the clinic 2 days after sustaining a sprain to the left ankle. What intervention can the nurse encourage the client to perform that will help improve circulation?
- A. Active range-of-motion exercises
- B. Take nonsteroidal anti-inflammatory drugs
- C. Applying cold compresses
- D. Applying heat
Correct Answer: D
Rationale: After 2 days, when swelling is no longer likely to increase, applying heat reduces pain and relieves local edema by improving circulation. Full use of the injured joint is discouraged temporarily. Nonsteroidal anti-inflammatory drugs will ease discomfort but not improve circulation. Applying cold compresses is only used in the first 24 to 48 hours after an injury to reduce swelling and relieve pain.
A client has sustained a left femur fracture in a skiing accident. When is the nurse aware that the complication of a fat emboli typically occurs and should be monitored for closely?
- A. The first hour after fracture of the long bone
- B. 8 to 12 hours
- C. 12 to 24 hours
- D. 48 to 72 hours
Correct Answer: D
Rationale: The client should be monitored for symptoms of a fat embolism, which typically occurs within 48 to 72 hours.