NUR 202 Exam 4
An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1. 18% 2. 24% 3. 36% 4. 48%
. 3 Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription? 1. Transfusing 1 unit of packed red blood cells 2. Administering a diuretic to increase urine output 3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4. Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water
. 3 Rationale: Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Lactated Ringer's solution is an isotonic solution that contains electrolytes that will maintain fluid volume in the circulation. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, the HCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. There is nothing in the situation that calls for blood resplacement, which is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because fluid replacement is needed. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Intravenous 5% dextrose solution is isotonic before administered but is hypotonic once the dextrose is metabolized. Hypotonic solutions are not appropriate for fluid resuscitation of a client with significant burn injuries.
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1. Return of distal pulses 2. Brisk bleeding from the site 3. Decreasing edema formation 4. Formation of granulation tissue
1 Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.
776. The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.
1, 2, 4Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.
773. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours
1, 2, 4Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
770The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure 5. Ensuring that the client has a bowel movement at least once a week
2 Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. 1. Lesion is painful to touch. 2. Lesion is highly metastatic. 3. Lesion is a nevus that has changes in color. 4. Skin under the lesion is reddened and warm to touch. 5. Lesion occurs in body area exposed to outdoor sunlight.
2, 3 Rationale: Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure increases the risk of melanoma, lesions are most commonly found on the upper back and legs and on the soles and palms of persons with dark skin.
A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.
2, 3, 5Rationale: The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm since the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.
The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? 1. Coma 2. Flushing 3. Dizziness 4. Tachycardia
2Rationale: Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.
The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses
2Rationale: Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.
The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1. Out-of-bed activities 2. Bathroom privileges 3. Immobilization of the affected leg 4. Placing the affected leg in a dependent position
3Rationale: Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound.
The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? 1. Using sterile sheets and linens 2. Performing strict hand-washing technique 3. Wearing gloves and a gown only when giving direct care to the client 4. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron
3Rationale: In protective isolation, the nurse needs to protect the client at all times from any potential infectious contact. Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client.
774. The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder
3Rationale: Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.
771. A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning
4Rationale: Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.
778. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self
4Rationale: Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.
777. The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."
4Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2. Oxygen via nasal cannula at 6 L/minute 3. Oxygen via nasal cannula at 15 L/minute 4. 100% oxygen via a tight-fitting, nonrebreather face mask
4Rationale: If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Administration of oxygen by aerosol mask and cannula are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion for the client with a likely inhalation injury.
772. A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.
4Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1. Decreased heart rate 2. Increased urinary output 3. Increased blood pressure 4. Elevated hematocrit levels
4Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.
A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best? a. Being able to sleep doesnt mean pain doesnt exist. b. Have you ever experienced any type of pain? c. The client should be assessed for drug addiction. d. Youre right; I would put the medication back.
A. clients description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede the clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the clients report of pain serves no useful purpose.
A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer. Which diagnostic test should the nurse anticipate being ordered for this client? a. Punch skin biopsy b. Viral cultures c. Woods lamp examination d. Diascopy
This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Woods lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates erythema, making skin lesions easier to examine.
A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered a test on my heart, how should the nurse respond? a. Most of these types of blood clots come from the heart. b. Some of the blood clots may have gone to your heart too. c. We need to see if your heart is strong enough for therapy. d. Your heart may have been damaged in the stroke too.
a An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.
After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.
a Ataxia is a gait disturbance. For the clients safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.
An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.
a Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.
A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.
a Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management.
The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. b. I will go back to work immediately. c. I will not feel anger about my situation. d. Once I get home, things will be normal.
a During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.
A nurse assesses a client who has a chronic wound. The client states, I do not clean the wound and change the dressing every day because it costs too much for supplies. How should the nurse respond? a. You can use tap water instead of sterile saline to clean your wound. b. If you dont clean the wound properly, you could end up in the hospital. c. Sterile procedure is necessary to keep this wound from getting infected. d. Good hand hygiene is the only thing that really matters with wound care.
a For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration.
A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications
a Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.
A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a. Keep the water temperature constant when showering the client. b. Assess the wound beds during the hydrotherapy treatment. c. Apply a topical enzyme agent after bathing the client. d. Use sterile saline to irrigate and clean the clients wounds.
a Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile saline.
After teaching a client with a spinal cord injury, the nurse assesses the clients understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. Ill use my incentive spirometer every 2 hours while Im awake. b. Ill drink thinned fluids to prevent choking c. Ill take cough medicine to prevent excessive coughing. d. Ill position myself on my right side so I dont aspirate.
a Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowlers position to prevent aspiration.
A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the clients skin. How should the nurse document these lesions?a. Two 2-cm hyperpigmented patchesb. Two 1-inch erythematous plaquesc. Two 2-mm pigmented papulesd. Two 1-inch moles
a Patches are larger flat areas of the skin. The information provided does not indicate a mole or the presence of erythema.
A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The clients mental status is deteriorating. What action by the nurse is most appropriate?a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.
a The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.
A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the clients score to be 36. How should the nurse plan care for this client? a. The client will need near-total care. b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home.
a This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the clients dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client.
A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care? a. Change the dressing every 6 hours. b. Assess the wound bed once a day. c. Change the dressing when it is saturated. d. Contact the provider when the dressing leaks.
a Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum dbridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.
A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.
a, b, c Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.
A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke
a, b, d, e, Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral.
A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control
a, b, e Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.
A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospitals gift shop. e. Use aseptic technique and wear gloves when performing wound care.
a, b, e To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the clients room.
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation
a, c, d, Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.
A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time Increased risk for loss of function from contracture formation b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance Increased risk for atelectasis d. High incidence of cardiac impairments Increased risk for acute kidney injury e. Thinner skin May not exhibit a fever when infection is present
a, c, d, Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.
A nursing student is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.) a. Neuropathic pain sometimes accompanies amputation. b. Nociceptive pain originates from abnormal pain processing .c. Deep somatic pain is pain arising from bone and connective tissues. d. Somatic pain originates from skin and subcutaneous tissues. e. Visceral pain is often diffuse and poorly localized.
a, c, d, e Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.
A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.
a, c, d, e, A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.
The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking
a, c, d, e, Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.
A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the clients coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies
a, c, d, f Information about the clients preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the clients level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the clients spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.
A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism
a,d, e, Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.
A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6 F (38 C)
b A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.
The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the clients body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.
b Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the clients body can prevent autocontamination.
1. While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. Which action should the nurse take next?a. Ask the client about current medications he or she is taking.b. Use pulse oximetry to assess the clients oxygen saturation.c. Auscultate the clients lung fields for adventitious sounds.d. Palpate the clients bilateral radial and pedal pulses.
b Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments.
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)
b Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best?a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.
b Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.
A therapeutic touch practitioner scans the patients body to identify what? a. Blocked chakra b. Accumulated tension c. The flow of Qi d. Structural and functional imbalance
b The therapeutic touch practitioner scans the body to identify areas of accumulated tension. The practitioner will then attempt to redirect these accumulated energies back into balance. Chiropractic therapy involves balancing structural and functional imbalance through spinal manipulation. Qi is involved in traditional Chinese medicine. Chakras are involved in Reiki therapy.
A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the clients oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the clients intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.
b These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning.
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the clients neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)
b This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.
A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the nurse teach? a. Stroking the medial aspect of the thigh b. Valsalva maneuver c. Self-catheterization d. Frequent toileting
b With a flaccid bladder, the voiding reflex arc is not intact and additional stimulation may be needed to initiate voiding, such as with the Valsalva and Cred maneuvers. Intermittent catheterization may be used after the previous maneuvers are attempted. In reflex bladder, the voiding arc is intact and voiding can be initiated by any stimulus, such as stroking the medial aspect of the thigh. A consistent toileting routine is used to re-establish voiding continence with an uninhibited bladder.
A faculty member explains to students the process by which pain is perceived by the client. Which processes does the faculty member include in the discussion? (Select all that apply.) a. Induction b. Modulation c. Sensory perception d. Transduction e. Transmission
b, c, d, e The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission.
A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.
b. e, The UAP can take and document vital signs, including oxygen saturation, and keep the clients head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a. Client with blood cultures pending b. Client who has thin, serous wound drainage c. Client with a white blood cell count of 23,000/mm3 d. Client whose wound has decreased in size
c A client with an elevated white blood cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a decrease in wound size are not indications that the client may have an infection.
A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? a. 9% b. 18% c. 27% d. 36%
c According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body.
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a. A 44-year-old prescribed IV antibiotics for pneumonia b. A 26-year-old who is bedridden with a fractured leg c. A 65-year-old with hemi-paralysis and incontinence d. A 78-year-old requiring assistance to ambulate with a walker
c Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.
The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero.
c House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140 F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.
A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week
c Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.
A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. I will allow my spouse to change my dressings. b. I want to have surgical reconstruction. c. I will bathe and dress before breakfast. d. I have secured the pressure dressings as ordered.
c Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.
A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.
c Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.
A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? a. With reconstructive surgery, you can look the same. b. We can remove the scars with the use of a pressure dressing. c. You will not look exactly the same but cosmetic surgery will help. d. You shouldnt start worrying about your appearance right now.
c Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.
A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better. How should the nurse respond? a. If you dont want to participate in the rehabilitation program, Ill let the provider know. b. Rehabilitation programs have helped many clients with your injury. You should give it a chance. c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability. d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.
c Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this clients needs.
A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? a. You should change the batteries in your smoke detector once a year. b. Join a program that assists burn clients to reintegration into the community. c. I will demonstrate how to change your wound dressing for you and your family. d. Let me tell you about the many options available to you for reconstructive surgery.
c Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.
A nurse reviews the following data in the chart of a client with burn injuries: Admission Notes Wound Assessment 36-year-old female with bilateral leg burns NKDA Health history of asthma and seasonal allergies Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this clients injuries? a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial
c The characteristics of the clients wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.
A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.
c The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.
A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L
c The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.
A patient describes practicing a complementary and alternative therapy involving concentrating and controlling his respiratory rate and pattern, recognizing that breath work is to yoga as a. The zone is to acupressure. b. Massage therapy is to Ayurveda. c. Reiki therapy is to therapeutic touch. d. Prayer is to tai chi.
c This is an analogy that compares different therapies within specific categories. Both yoga and breath work are mind-body therapies, whereas both Reiki and therapeutic touch therapies are energy field therapies. The other options have different design structures; thus, they do not fit the analogy.
After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. I will explore other ways besides intercourse to please my partner. b. I will not be able to have an erection because of my injury. c. Ejaculation may not be as predictable as before. d. I may urinate with ejaculation but this will not cause infection. e. I should be able to have an erection with stimulation.
c, d, e, Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the clients partner will not get an infection.
A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.
c, e Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the clients risk of respiratory complications but will not decrease pressure on the clients hips and sacrum.
A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction? a. Insert an indwelling urinary catheter. b. Stroke the medial aspect of the thigh. c. Use the Cred maneuver every 3 hours. d. Apply a Texas catheter with a leg bag.
c. Two techniques are used to facilitate voiding in a client with a flaccid bladder: the Valsalva maneuver and the Cred maneuver. Indwelling urinary catheters generally are not used because of the increased incidence of urinary tract infection. Stroking the medial aspect of the thigh facilitates voiding in clients with upper motor neuron problems. If the spinal cord injury is above T12, the client is unaware of a full bladder and does not void or is incontinent. Therefore, the client would not benefit from a Texas catheter with a leg bag.
A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowlers position. d. gather appropriate equipment and prepare for an emergency airway.
d Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.
The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the clients wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the clients room.
d Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.
A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond? a. When the antibiotic therapy is complete. b. as soon as his albumin levels return to normal. c. Once we complete the fluid resuscitation process. d. When all of his burn wounds have closed.
d Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the clients recovery process, they are not as important as skin closure to decrease the clients risk for infection.
A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.
d Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.
d The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset
d The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.
A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the clients lungs after eating or drinking. c. Prop the clients right side up when sitting in a chair. d. Rotate the clients meal tray when the client stops eating.
d This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.
A nurse teaches a client about performing intermittent self-catheterization. The client states, I am not sure if I will be able to afford these catheters. How should the nurse respond? a. I will try to find out whether you qualify for money to purchase these necessary supplies. b. Even though it is expensive, the cost of taking care of urinary tract infections would be even higher. c. Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each. d. You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.
d. At home, clean technique for intermittent self-catheterization is sufficient to prevent cystitis and other urinary tract infections. The nurse would refer the client to the social worker to explore financial concerns. The nurse should not threaten the client, nor should the client be instructed to boil the catheters.
A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Objective observation d. Clients self-report
d. Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.
