the nurse should teach a client in the emergency department who has suffered an ankle sprain to the nurse should teach a client in the emergency department who has suffered an ankle sprain to
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NCLEX NCLEX-PN

NCLEX PN Exam Cram

1. The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:

Correct answer: use cold applications to the sprain during the first 24–48 hours.

Rationale: When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24–48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice B) is incorrect as disability and pain are anticipated to increase during the first 2–3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice D) is not recommended; these exercises are usually started 2–5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.

2. The new mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:

Correct answer: The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breastfeeding.

Rationale: After birth, newborns can lose weight due to meconium stool, loss of extracellular fluid, and the initiation of breastfeeding. This weight loss is a normal and expected physiological process, and infants can lose up to 10% of their birth weight during this period. There is no indication of dehydration (polyuria), hypoglycemia (lack of glucose), or allergy to the formula as reasons for weight loss in newborns. Therefore, answers A, B, and C are incorrect. Answer D provides the most accurate explanation for the observed weight loss in the newborn.

3. Which laboratory test would be the least effective in diagnosing a myocardial infarction?

Correct answer: A: AST

Rationale: AST, choice A, would be the least effective in diagnosing a myocardial infarction as it is not specific for this condition. Troponin, CK-MB, and myoglobin (choices B, C, and D) are more specific markers for myocardial infarction. Troponin is considered the gold standard due to its cardiac specificity. CK-MB is also specific to the heart, and its isoenzyme levels elevate post-heart damage. Myoglobin, although elevated in myocardial infarction, is not as specific as troponin and CK-MB and can also increase in conditions like burns and muscle trauma. Therefore, AST is the least effective choice for diagnosing a myocardial infarction.

4. A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?

Correct answer: “I will call your physician to see if we can start some ginger.”

Rationale: The correct response is appropriate as it demonstrates cultural sensitivity. Ginger is commonly used to alleviate nausea, particularly in Asian cultures. Contacting the physician to discuss the use of ginger ensures the client's safety and respects their preferences. Choices B and C are incorrect as they disregard the client's request and fail to acknowledge their cultural beliefs. Choice D is incorrect because it does not address the client's desire to use ginger for relief.

5. A client asks the nurse what risk factors increase the chances of getting skin cancer. The risk factors include all except:

Correct answer: certain diet and foods.

Rationale: The correct answer is 'certain diet and foods.' Risk factors that increase the chances of getting skin cancer include having a light or fair complexion, a history of bad sunburns, personal or family history of skin cancer, outdoor activities with sun exposure, exposure to X-rays or radiation, exposure to certain chemicals, repeated trauma or injury resulting in scars, age over 50, male gender, and living in specific geographic locations. These factors can contribute to the development of skin cancer. Avoiding exposure to the sun, using protective clothing and sunscreen, and regular skin inspections are key preventive measures. Choice C, 'certain diet and foods,' is incorrect as diet is not a primary risk factor for skin cancer. Options A, B, and D are all valid risk factors associated with an increased risk of developing skin cancer.

Similar Questions

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