EXAM 2

B. Computed tomography (CT) scan

A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the client's peritoneum, the nurse should anticipate what diagnostic test? A. Complete blood count (CBC) B. Computed tomography (CT) scan C. Radiograph D. Barium swallow

D. Paradoxical chest movement

A client admitted to the hospital following a motor vehicle crash has suffered a flail chest. The nurse assesses the client for what most common clinical manifestation of flail chest? A. Cyanosis B. Hypertension C. Wheezing D. Paradoxical chest movement

A. Alteration in level of consciousness (LOC)

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? A. Alteration in level of consciousness (LOC) B. Bradycardia C. Slurred speech D. Decreased heart rate

D. Protect the client from injury.

A client the nurse is caring for experiences a seizure. What would be a priority nursing action? A. Restrain the client during the seizure. B. Suction the mouth during the convulsion. C. Insert a tongue blade between the teeth. D. Protect the client from injury.

D. The total body surface area (TBSA) affected by the burn

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? A. The length of time since the burn B. The source of the burn C. The location of burned skin surfaces D. The total body surface area (TBSA) affected by the burn

D. Speak slowly and in short sentences.

Because of the pain in her facial muscles and jaws a young female client with Bell's palsy is upset because she is unable to communicate properly. What advice can be given to the client to improve her speech? A. Speak in monosyllables. B. Don't speak but instead gesticulate. C. Speak in short sentences but loudly. D. Speak slowly and in short sentences.

A. Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries.

For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority? A. Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries. B. Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage. C. Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock. D. Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries.

A. Compartment syndrome

In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor? A. Compartment syndrome B. Carpal tunnel syndrome C. Gastrointestinal bleeding D. Ganglion cysts

A. Aspiration

Nurse understands that the client with myasthenia gravis is at highest risk for which? A. Aspiration B. Bladder dysfunction C. Hypertension D. Sensory loss

3, 1, 2, 4

Prioritize the following interventions in order for a patient actively having a seizure: 1. Maintain a patent airway. 2. Record the seizure activity observed. 3. Ease the client to the floor. 4. Obtain vital signs.

A. Absence of breath sounds in the right thorax

On auscultation, which finding suggests a right pneumothorax? A. Absence of breath sounds in the right thorax B. Bilateral pleural friction rub C. Inspiratory wheezes in the right thorax D. Bilateral inspiratory and expiratory crackles

?

Patient receiving large volumes of fluid to treat hypovolemic. For what should RN monitor related to this intervention? A. Coffee ground emesis B. Pain C. Hypothermia D. Bradycardia

D. Greenstick

Radiographs of a boy's upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture? A. Compression B. Compound C. Impacted D. Greenstick

C. A normal finding; the fluid will be sent for testing to determine other factors

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? A. A subarachnoid hemorrhage B. An overwhelming infection C. A normal finding; the fluid will be sent for testing to determine other factors D. Local trauma from the insertion of the needle

C. As people get older, their immune system does not respond as well as it did when they were younger.

The daughter of a 79-year-old woman asks the nurse why her mother gets so many infections. The daughter states, "My mother has always been healthy, but now she has pneumonia. Last month she got cellulitis from a bug bite she scratched. The month before that was some other infection. How come she seems to get sick so often now?" What is the nurse's best response? A. Your mother gets infections frequently because she wants attention from you. B. Your mother just seems to be prone to getting infections. C. As people get older, their immune system does not respond as well as it did when they were younger. D. About the time we are 75 or 76 years old, our immune system quits working.

D. Skin and mucous membranes

The first physical line of defense in innate immunity is: A. Specialized lymphocytes B. Neutrophils C. Plasma proteins D. Skin and mucous membranes

C. CD4+ T lymphocytes

The human immunodeficiency virus (HIV) acts on which type of cells? A. CD8+ T lymphocytes B. White blood cells C. CD4+ T lymphocytes D. Red blood cells

C. "Immunization is an important means of inhibiting the spread of infection by decreasing your child's susceptibility to the infection."

The nurse is administering a childhood vaccine to a pediatric client. The mother asks the nurse why the child needs so many vaccinations. How should the nurse respond? A. "Childhood vaccinations are required by law; all children must be vaccinated before attending school." B. "Immunization assures that your child will never contract the disease." C. "Immunization is an important means of inhibiting the spread of infection by decreasing your child's susceptibility to the infection." D. "Immunization inhibits the spread of infection by blocking the mode of transmission."

C. Anhidrosis

The nurse is admitting a client who is suspected of having heat stroke. What assessment finding would be most consistent with this diagnosis? A. Copious diuresis B. Cheyne-Stokes respirations C. Anhidrosis D. Hypertension with a wide pulse pressure

A. Pneumothorax

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A. Pneumothorax B. Acute bronchitis C. Cardiac ischemia D. Aspiration

?? B. Initial symptoms

There is a lag time or "window period" after the initial HIV infection. This refers to the period of time between infection and which of the following? A. Transmission B. Initial symptoms C. Seroconversion D. Antibody screening

B. Check response of pupils to light

What assessment should the nurse perform after administering mannitol to the client with increased ICP? A. Monitor BP every four hours B. Check response of pupils to light C. Monitor for joint pain D. Monitor serum uric acid concentrations

A. Brain and spinal cord

Which components of the nervous system make up the central nervous system? A. Brain and spinal cord B. Dendrites and axons C. Neurohormones and neurosecretory granules D. Specialty Cells

A. Administer stool softeners.

Which intervention should the nurse include in the care plan to reduce ICP? A. Administer stool softeners. B. Provide sensory stimulation. C. Position the client with the head turned toward the side D. Encourage coughing and deep breathing.

C. Cerebrospinal fluid

Which intracranial volume is most capable of compensating for increasing intracranial pressure? A. Surface sulci fluid B. Intravascular blood C. Cerebrospinal fluid D. Brain cell tissue

D. Ensuring continuous ECG monitoring

A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the client? A. Assessing the client's oral temperature frequently B. Administering bronchodilators by nebulizer C. Massaging the client's skin surfaces to promote circulation D. Ensuring continuous ECG monitoring

A. Basilar

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture? A. Basilar B. Comminuted C. Linear D. Simple

E. Full thickness

A client is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm? A. No answer text provided. B. Full partial thickness C. Deep partial thickness D. Superficial partial thickness E. Full thickness

A. Decreased blood pressure

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? A. Decreased blood pressure B. High fever C. Confusion D. Sudden agitation

A. Lactated Ringer's

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A. Lactated Ringer's B. 0.45% NaCl with 40 mEq/L KCl C. 0.45% NaCl with 20 mEq/L KCl D. Normal saline

A. Rapid pulse and decreased capillary refill

A male client with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A. Rapid pulse and decreased capillary refill B. Sudden diaphoresis C. Increased BP with narrowed pulse pressure D. Absence of bruising at contusion sites

C. Tachypnea and restlessness

A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority? A. Frequent loose stools B. Weight loss of 1 pound since yesterday C. Tachypnea and restlessness D. Oral temperature of 100°F

C. diminished or absent breath sounds on the affected side.

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include: A. paradoxical chest wall movement with respirations. B. muffled or distant heart sounds. C. diminished or absent breath sounds on the affected side. D. tracheal deviation to the unaffected side.

C. Standard

A nurse is caring for a client who has HIV. Which of the following infection control precautions should the nurse use while caring for this client? A. Droplet B. Airborne C. Standard D. Contact

D. Acute Pain

A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A. Activity Intolerance B. Ineffective Coping C. Anxiety D. Acute Pain

D. CD4 T-cell count 180/mm3

A nurse is caring for a client with Human Immunodeficiency Virus (HIV). Which of the following laboratory values should be of most concern to the nurse? A. Elevated C-reactive protein (CRP) B. WBCs 4900/mm3 C. Positive Western blot test D. CD4 T-cell count 180/mm3

A. Flu-like symptoms and night sweats

A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following should the nurse include in the explanation of initial symptoms? A. Flu-like symptoms and night sweats B. Pneumocystis lung infection C. Kaposi's sarcoma D. Fungal and bacterial infections

A. Serum creatinine

A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function? A. Serum creatinine B. Urine specific gravity C. Serum sodium D. Blood urea nitrogen (BUN)

C. Education about home safety

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? A. Education about safe storage of chemicals B. Education about workplace health threats C. Education about home safety D. Education about safe driving

C. Neutrophils

A teenager with an infected wound asks, "How does my body fight off the germs in my scraped arm?" Which response by the nurse correctly identifies the cells that play a central role to the innate immune response to an infectious microorganism? A. T lymphocytes B. Antibodies C. Neutrophils D. B lymphocytes

B. "If you use latex condoms with water-soluble lubricant consistently, sex is safer, but not completely risk-free."

The nurse is caring for a client who has been told that he is HIV infected. The client asks the nurse, "Can my partner and I ever have sex again?" What is an appropriate response by the nurse? A. "To be safe, you should never have sex again." B. "If you use latex condoms with water-soluble lubricant consistently, sex is safer, but not completely risk-free." C. "Engaging in oral sex will not transmit the virus." D. "If your viral load is low, you can safely have intercourse without risk of transmitting the virus."

A. Family members should not come in contact with your blood.

The nurse is teaching a male client who has been diagnosed as HIV positive. The client asks what precautions he should take to prevent his family members from contracting HIV. Which statement will the nurse include in teaching this client? A. Family members should not come in contact with your blood. B. You and your family members should use separate toilet facilities. C. Dishes and eating utensils should be soaked in bleach. D. You should not place your toothbrush near the other family members' toothbrushes.

C. "That's something that you and your doctor will likely talk about after your scars mature."

A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response? A. "I know this is really important to you, but you have to realize that no one can make you look like you used to." B. "Unfortunately, it's likely that these scars will look like this for the rest of your life." C. "That's something that you and your doctor will likely talk about after your scars mature." D. "That is something for you to talk to your doctor about because it's not a nursing responsibility."

C. Ineffective breathing pattern

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? A. Impaired physical mobility B. Dressing or grooming self-care deficit C. Ineffective breathing pattern D. Disturbed sensory perception (tactile)

D. Giving milk to drink

A client is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The client is alert and oriented. What is the care team's most appropriate treatment? A. Administering syrup of ipecac B. Referring to psychiatry C. Performing a gastric lavage D. Giving milk to drink

A. Keep an elastic compression bandage on the ankle.

A nurse is preparing to discharge a client from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage what action? A. Keep an elastic compression bandage on the ankle. B. Exercise hourly by performing rotation exercises of the ankle. C. Maintain the ankle in a dependent position. D. Apply heat for the first 24 to 48 hours after the injury.

A. 200 cells/mm3 of blood

A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold? A. 200 cells/mm3 of blood B. 450 cells/mm3 of blood C. 75 cells/mm3 of blood D. 325 cells/mm3 of blood

A. Risk for Infection

A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? A. Risk for Infection B. Risk for Ineffective Role Performance C. Risk for Powerlessness D. Risk for Perioperative Positioning Injury

D. CD4+ count less than 200 cells/μL

Which of these is an AIDS-defining condition? A. Severe, prolonged diarrhea B. Any serious infection C. Malignancy of any organ D. CD4+ count less than 200 cells/μL

C. IV diazepam

Which med would be used to halt a seizure immediately? A. PO lorazepam B. PO phenytoin C. IV diazepam D. IV phenobarbital

A. An attempt to increase cerebral perfusion

The nurse is conducting a staff inservice on increased intracranial pressure. The nurse determines that the participants are understanding the information when they identify that blood pressure increases in increased intracranial pressure because of which pathophysiologic response? A. An attempt to increase cerebral perfusion B. Constriction of cerebral arteries C. Decreased metabolic demand D. Increase in pulse rate

A. Decorticate posturing

The nurse observes that the upper extremities of a client with a brain injury are abducted while the lower extremities are internally rotated. The nurse communicates which terminology during hand-off reporting A. Decorticate posturing B. Increased intracranial pressure C. Persistent vegetative state D. Decerebrate posturing

A. Immerse affected extremities in water slightly above normal body temperature.

A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the client's frostbite? A. Immerse affected extremities in water slightly above normal body temperature. B. Perform passive range-of-motion exercises of the affected extremities to promote circulation. C. Gently massage the client's frozen extremities in between water baths. D. Immerse the client's frostbitten extremities in the warmest water the client can tolerate.

C. Monitor temperature and pulses of the affected extremity.

A client has sustained a long bone fracture and the nurse is preparing the client's care plan. Which of the following should the nurse include in the care plan? A. Perform passive range of motion exercises as tolerated. B. Administer vitamin D and calcium supplements as prescribed. C. Monitor temperature and pulses of the affected extremity. D. Administer corticosteroids as prescribed.

D. Airway management

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A. Anxiety and fear B. Pain C. Fluid balance D. Airway management

C. Clearly document LOC and health status on the client's chart.

A client is brought to the ER in an unconscious state. The health care provider notes that the client is in need of emergency surgery. No family members are present, and the client does not have identification. What action by the nurse is most important regarding consent for treatment? A. Ask the social worker to come and sign the consent. B. Obtain a court order to treat the client. C. Clearly document LOC and health status on the client's chart. D. Contact the police to obtain the client's identity.

A. Perform endotracheal intubation.

A client is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the health care provider will perform which of the following actions? A. Perform endotracheal intubation. B. Perform a cricothyroidotomy. C. Insert an oropharyngeal airway. D. Perform the jaw thrust maneuver.

B. Removing all metal-containing objects

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? A. Withholding stimulants 24 to 48 hours prior to exam B. Removing all metal-containing objects C. Instructing the patient to void prior to the MRI D. Initiating an IV line for administration of contrast

A. "The booster shot will stimulate your immune system's memory, causing an immediate rise in antibodies to protect you from an infection."

A client stepped on a nail at work. The emergency room physician prescribes a tetanus "booster" shot. The client asks the nurse, "If I have already been vaccinated for tetanus why do I need to have another shot?" How should the nurse respond? A. "The booster shot will stimulate your immune system's memory, causing an immediate rise in antibodies to protect you from an infection." B. "Your initial vaccination is outdated so you are no longer immune to tetanus." C. "Tetanus can mutate and form a new strain; therefore yearly vaccinations are recommended." D. "If you have questions about your treatment, I will ask the physician to come back in and talk to you."

A. Prepare the client for opening or bivalving of the cast.

A client was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the client tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A. Prepare the client for opening or bivalving of the cast. B. Petal the edges of the client's cast. C. Obtain a prescription for a different analgesic. D. Encourage the client to wiggle and move the fingers.

B. Candidiasis

A nurse in a clinic is assessing a client who has AIDS, has a significantly decreased CD4 cell count, and is at increased risk for infection. The nurse should recognize that the client is likely to have which of the following infectious oral conditions? A. Halitosis B. Candidiasis C. Gingivitis D. Xerostomia

A. maintaining the client's fluid, electrolyte, and acid-base balance.

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: A. maintaining the client's fluid, electrolyte, and acid-base balance. B. planning for the client's rehabilitation and discharge. C. preserving full range of motion in all affected joints. D. providing emotional support to the client and family.

C. To prevent contractures

A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A. To prevent heterotopic ossification B. To prevent wound breakdown C. To prevent contractures D. To prevent neuropathies

D. Ineffective Airway Clearance

A nurse is planning the care of a patient with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient? A. Impaired Oral Mucous Membranes B. Activity Intolerance C. Imbalanced Nutrition: Less than Body Requirements D. Ineffective Airway Clearance

C. "Are you allergic to seafood or iodine?"

A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? A. "When did you last have something to eat or drink?" B. "When did you last take any medication?" C. "Are you allergic to seafood or iodine?" D. "How much do you weigh?"

A. inability to perform active movement and pain with passive movement.

A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include: A. inability to perform active movement and pain with passive movement. B. body-wide decrease in bone mass. C. inability to perform passive movement and pain with active movement. D. a growth in and around the bone tissue.

A. Addressing possible barriers to adherence

A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy? A. Addressing possible barriers to adherence B. Promoting appropriate use of complementary therapies C. Educating the patient about the pathophysiology of HIV D. Teaching the patient about the need for follow-up blood work

C. Coffee

A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test? A. Orange juice B. Toast C. Coffee D. Eggs

C. Immerse the child in a cool bath.

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What should the nurse in the ED receiving the call instruct the father to do? A. Apply butter to the area that is burned. B. Cover the burn with ice and secure with a towel. C. Immerse the child in a cool bath. D. Avoid touching the burned area under any circumstances.

C. Lymphocytes

Adaptive immune responses, also called acquired or specific immunity, are composed primarily of which type of cells? A. Epithelial cells B. Granulocytes C. Lymphocytes D. Toll-like receptors

D. Administer IV fluids

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A. Administer IV potassium chloride B. Administer packed red blood cells C. Administer broad-spectrum antibiotics D. Administer IV fluids

D. The causative agent

An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A. The circumstances of the accident B. The client's prognosis for recovery C. The client's pre-injury health status D. The causative agent

B. Wrap cool towels around the affected extremity intermittently.

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? A. Apply an oil-based substance to the burned area until help arrives. B. Wrap cool towels around the affected extremity intermittently. C. Wrap the client's affected extremity in ice until help arrives. D. Apply ice to the site of the burn for 5 to 10 minutes.

D. Intubation tray and suction apparatus

The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside? A. Incentive spirometer B. Blood pressure apparatus C. Nebulizer and thermometer D. Intubation tray and suction apparatus

B. Mannitol

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? A. Urea B. Mannitol C. Glycerin D. Isosorbide

C. Monitoring is needed as rapid neurological deterioration may occur.

Which of following facts of the disease progression is essential to guide the nursing management of client care with an epidural hematoma? A. The crash cart with defibrillator is kept nearby. B. Symptoms will evolve over a period of 1 week. C. Monitoring is needed as rapid neurological deterioration may occur. D. Bleeding continues into the intracerebral area.

B. our mucosal tissue contains all the necessary cell components to fight a pathogen with an immune response."

While explaining immunity to a client, the nurse responds, "The body's internal organs are protected from pathogens because: A. we have special glands that can secrete cytokines on a moment's notice." B. our mucosal tissue contains all the necessary cell components to fight a pathogen with an immune response." C. the actions of the cytokines in the mouth can act on different cell types at the same time it is fighting pathogens." D. the tonsils store a large amount of natural killer cells at that location."

A. The client may be experiencing anger about his circumstances that he is deflecting toward the nurse.

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this client's behavior? A. The client may be experiencing anger about his circumstances that he is deflecting toward the nurse. B. The client may be experiencing an adverse drug reaction that is affecting his cognition and behavior. C. The client may be experiencing inconsistencies in the care that he is being provided. D. The client may be experiencing neurologic or psychiatric complications of his injuries.