Author Question: A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse ... (Read 208 times)

Zoey63294 · **on:** Jul 22, 2018

A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. What is the nurse's best response?

a. Use ice only when the ankle hurts.
b. Ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days.
c. Wrap an ice pack around the injured ankle for the next 24 to 48 hours.
d. Ice is not recommended for use on the sprain because it would inhibit the inflammatory response.

Question 2

On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient's wound. The nurse realizes what information about this fluid?

a. Contains the materials used by the body in the initial inflammatory response.
b. Indicates that the patient has an infection at the site of the wound.
c. Is destroying healthy tissue.
d. Results from ineffective cleansing of the wound area.

kswal303 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: B
Ice is used on areas of injury during the first 24 to 48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2 to 3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

Answer to Question 2

ANS: A
Exudate is fluid moved from the vascular spaces to the area around a wound. It contains the proteins, fluid, and white blood cells (WBCs) needed to contain possible pathogens at the site of injury. Exudate appears as part of all inflammatory responses and does not mean an infection is present. Exudate is part of normal inflammatory responses which contain self-monitoring mechanisms to help prevent damage to healthy tissue. Exudate appears at wound sites regardless of cleaning done to the area of injury.