HCIV Unit 4 Exam
A patient has full-thickness burns on the front and back of both arms and hands. It is a nursing priority to: (RegisteredNurseRN Burns Quiz) A) Elevate and extend the extremities B) Elevate and flex the extremities C) Keep extremities below heart level and extended D) Keep extremities level with the heart level and flexed
A) Elevate and extend the extremities Rationale: This position will decrease edema, which will help prevent compartment syndrome.
An unconscious client with multiple injuries to the head and neck arrived in the ED. What should the nurse do first? (Lippincott Test 11 pg 553 #6) A) Establish an airway B) Determine the identity of the client C) Stop the bleeding from open wounds D) Check for a neck fracture
A) Establish an airway
The nurse is caring for a client who has a burn in the emergent stage. Which assessment is the highest priority? (Evolve) A) Extent of burn B) Cause of burn C) Where it occurred D) Type of first aid given
A) Extent of burn
A client admitted with a burn injury has erythema and mild swelling. Which type of burn would the nurse suspect? (Evolve) A) First-degree burn B) Third-degree burn C) Fourth-degree burn D) Second-degree burn
A) First-degree burn
The nurse is caring for a client with a body surface burn injury of 55%. Which information will the nurse consider when planning care for this client? (Evolve) A) Is prone to poor healing because of a hypermetabolic state B) Has a decreased risk of infection when in a hypermetabolic state C) Needs a cool environment to decrease caloric need D) Will need 20 calories/kg during the healing process
A) Is prone to poor healing because of a hypermetabolic state Rationale: Burn injuries cause a hypermetabolic state which results in lipid and protein breakdown, which in turn can inhibit wound healing.
The nurse provides discharge teaching for a client diagnosed with a thoracic SCI. Which activity does the nurse teach the caretakers to do to prevent contractures from occurring? (Kaplan) A) Perform ROM exercises B) Turn the client in bed every 4-6 hours C) Initiate flexor muscle spasms regularly D) Massage the client's calves and thighs
A) Perform ROM exercises
Which respiratory pattern indicates increasing ICP in the brain stem? (Lippincott Test 11 pg 553 #10) A) Slow, irregular respirations B) Rapid, shallow respirations C) Asymmetric chest excursion D) Nasal flaring
A) Slow, irregular respirations
The nurse assesses a client who sustained a thermal burn injury. The nurse is most concerned if which observation is made? (Kaplan) A) The client has singed nasal hairs B) The client has a BP of 100/62 C) The client has blisters on the hands D) The client's cap refill time is < 3 seconds
A) The client has singed nasal hairs
A client is at risk for inreased ICP. Which finding is the priority for the nurse to monitor? (Lippincott Test 11 pg 553 #8) A) Unequal pupil size B) Decreasing systolic BP C) Tachycardia D) Decreasing body temperature
A) Unequal pupil size
A client has burns on both hands and upper arms. Which nursing actions will be most helpful in preventing contractures? SATA. (Lippincott Test 16 pg 697 #16) A) Keep the hands elevated B) Administer narcotic pain medications every 3 hours C) Wash the fingers, hands, and upper arms with cool water D) Apply moisturizer to the hands and fingers E) Apply splints as prescribed F) Collaborate with the physical therapist
A, E, F
The nurse knows a client has a good understanding of emotional/psychological needs post severe burn injury when the client makes which statement? (Kaplan) A) "Everything will fall into place at the right time, I'm choosing to see good in all of this." B) "I will have to talk to future partners honestly about my decreased sensation and body image issues." C) "I'm determined to return to 100% function within 6 months." D) "I will have to find new friends, as I won't ever be able to participate in rugby again."
B) "I will have to talk to future partners honestly about my decreased sensation and body image issues."
A 25-year-old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned. (RegisteredNurseRN Rule of Nines Quiz) A) 46% B) 37% C) 36% D) 28%
B) 37%
Which intervention would the nurse perform first for a client with a spinal cord injury who is experiencing autonomic dysreflexia? (Evolve) A) Assess for the cause B) Place the client in a sitting position C) Check the client for fecal impaction D) Give an alpha blocker prophylactically
B) Place the client in a sitting position
A client reports dyspnea the 3rd day after a major burn episode. The client has crackles in both lower lung fields, the urine output is 125 mL/hr, and the CVP is 14 mmHg. Which statement is the correct interpretation of this data? (Kaplan) A) The client is developing shock B) The client is in the acute phase of burn injury C) The client is exhibiting normal response to burn injury D) The client is developing hypostatic pneumonia
B) The client is in the acute phase of burn injury
A 65-year-old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse, you know this patient is at risk for the following: SATA. (RegisteredNurseRN Burns Quiz) A) Acute kidney injury B) Dysrhythmia C) Iceberg effect D) Hypernatremia E) Bone fractures F) Fluid volume overload
B, C, E
The nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate the potential respiratory obstruction? SATA. (Evolve) A) Soot on legs B) Brassy cough C) Deep breathing D) Singed nasal hair E) Dark mucous membranes
B, D, E
A 68-year-old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area percentage. (RegisteredNurseRN Rule of Nines Quiz) A) 40.5% B) 49.5% C) 58.5% D) 67.5%
C) 58.5%
A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath? (Lippincott Test 16 pg 697 #7) A) Soak the dressing B) Remove the dressing C) Administer an analgesic D) Slit the dressing with blunt scissors
C) Administer an analgesic
What is the nurse's best interpretation when a client with a TBI and increased ICP develops severe hypertension with widened pulse pressure and bradycardia? (Iggy Workbook pg 384 #24) A) The client needs an emergency craniotomy B) Intravenous antihypertensive drugs will be administered C) This is a late sign of increased ICP and death is imminent D) A cardiac monitor should be placed followed by IV atropine
C) This a late sign of increased ICP and death is imminent
The nurse teaches a class on first aid at a community center. Which instruction is the most appropriate initial care for a person experiencing an electrical burn? (Kaplan) A) Tell the burned person to stop, drop, and roll B) Assess the burned person for an unobstructed airway C) Turn off the electrical current D) Remove the burned person's clothing
C) Turn off the electrical current
The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? (Lippincott Test 16 pg 696 #5) A) Pulse rate of 112 bpm B) BP of 94//64 C) Urine output of 30 mL/hr D) Serum sodium level of 136
C) Urine output of 30 mL/hr
A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temperature 99°F, pulse 100 bpm, respirations 18 breaths/min, and BP 140/70. The nurse should report which changes, should they occur, to the HCP? SATA. (Lippincott Test 11 pg 555 #24) A) Decreasing urinary output B) Decreasing systolic BP C) Bradycardia D) Widening pulse pressure E) Tachycardia F) Increasing diastolic BP
C, D
A 35-year-old male patient has full thickness burns to the anterior and posterior head and neck, front of left leg, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned. (RegisteredNurseRN Rule of Nines Quiz) A) 37% B) 14.5% C) 29% D) 19%
D) 19%
The nurse is assessing a client with a head injury for decerebrate posturing. Which positions indicates the client has decerebrate posturing? (Lippincott Test 11 pg 554 #21) A) Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers B) Back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet C) Supination of arms and dorsiflexion of the feet D) Back arched and rigid extension of all four extremities
D) Back arched and rigid extension of all four extremities
48 hours after a client's burn injury, the nurse notes large amounts of edema in all burned areas. The nurse monitors the client for signs and symptoms of hypovolemic shock. Which is a factor that contributes to the development of hypovolemic shock in the burn client? (Kaplan) A) Large urine output B) Decreased insensible fluid loss C) Decreased hematocrit D) Increased capillary permeability
D) Increased capillary permeability
Which mobility goal does the nurse expect for a client diagnosed with a SCI at the level of L-5? (Kaplan) A) Wheelchair bound but independent B) Limited ambulation with bilateral long leg braces C) Ambulation with short leg braces D) Independent ambulation without equipment
D) Independent ambulation without equipment Rationale: A client with an L-5 injury would be able to ambulate, although the client could possibly have some weakness of the muscles that raise the foot and big toe. The client should have sufficient plantar flexion to push off at the end of the stance.
A client sustains a crushing injury of the spinal cord above the level of the origin of the phrenic nerve. As a result of this injury, the nurse expects to react to which clinical manifestation? (Evolve) A) Ventricular fibrillation and decreased perfusion B) Dysfunction of the vagus nerve with hiccups C) Retention of sensation but paralysis of the lower extremities D) Respiratory paralysis and cessation of diaphragmatic contractions
D) Respiratory paralysis and cessation of diaphragmatic contractions
A client is admitted with a 45% partial and full-thickness burn. Which finding would alert the nurse that the client has a deficiency in fluid volume during the first 24 hours? (Lippincott Test 16 pg 697 #6) A) Serum creatinine level of 1.1 B) Serum potassium level of 3.7 C) Oxygen saturation of 94% D) Urine output of <30 mL/hr
D) Urine output of <30 mL/hr
In which order based on priority would the ED nurse perform interventions for a severely traumatized client with difficulty breathing because of debris in the mouth, external hemorrhaging, symptoms of severe hypoglycemia, and bruises on the skin? All answers must be used. (Evolve) 1) Administer IV glucose 2) Apply pressure bandages to the bleeding areas 3) Apply bandages on the bruises 4) Remove the debris from the mouth
4, 2, 1, 3
A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a: (RegisteredNurseRN Burns Quiz) A) 1st degree (superficial) burn B) 2nd degree (partial-thickness) burn C) 3rd degree (full-thickness) burn D) 4th degree (deep full-thickness) burn
A) 1st degree (superficial) burn
A 58-year-old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned. (RegisteredNurseRN Rule of Nines Quiz) A) 63% B) 81% C) 72% D) 54%
A) 63%
A 58-year-old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? (RegisteredNurseRN Burns Quiz) A) 63% B) 81% C) 72% D) 54%
A) 63%
Which example is associated with third spacing in a burn injury? (Evolve) A) Blister formation B) Edema formation C) Fluid mobilization D) Fluid accumulation
A) Blister formation
What are some patient priorities during the emergent phase of burn management? SATA. (RegisteredNurseRN Burns Quiz) A) Fluid volume B) Respiratory status C) Psychosocial D) Wound closure E) Nutrition
A, B
While caring for a client with a burn injury in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sounds on exhalation. Which immediate action would be appropriate for the safe care of the client? SATA. (Evolve) A) Providing oxygen immediately B) Notifying the Rapid Response Team C) Considering it a normal observation D) Initiating an IV line and beginning fluid replacement E) Obtaining an ECG of the client
A, B
Which instruction(s) would the nurse provide for a cervical spine injury client with a halo in place? SATA. (Evolve) A) Attach the vest wrench to the jacket for emergency access B) Observe the pin sites and report purulent drainage to your doctor C) Check to make sure on finger fits between the device and your skin D) Perform neck range of motion by holding and pulling on the halo device E) Use a long, pointed object to reach any spots that are itchy while wearing the halo
A, B, C
Which priority teaching points will the nurse provide for a client with a spinal cord injury who is treated with a halo fixator vest? SATA. (Iggy Workbook pg 376 #22) A) Be careful when leaning forward or backward because the weight of the halo device alters balance B) Wear loose clothing, preferably with large openings for the head and arms C) Wash under the liner of the vest to prevent rashes or sores D) Support your head with a small pillow when sleeping to prevent unnecessary pressure and discomfort E) Do not drive because you can't turn your head from side to side so peripheral vision is impaired F) Increase fluids and fiber in the diet to prevent constipation
A, B, C, D, E, F
A patient arrives at the ED due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? SATA. (RegisteredNurseRN Burns Quiz) A) Carbonaceous sputum B) Hair singeing on the head and nose C) Lhermitte's Sign D) Bright red lips E) Hoarse voice F) Tachycardia
A, B, D, E, F
A patient arrives at the ED with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are oxygen saturation of 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will: SATA. (RegisteredNurseRN Burns Quiz) A) Place the patient in High Fowler's position B) Prep the patient for escharotomy C) Prep the patient for fasciotomy D) Prep the patient for intubation E) Place a pillow under the patient's neck F) Obtain IV access at two sites G) Restrict fluids
A, B, D, F
You are about to provide care to a patient with severe burns. You will don: SATA. (RegisteredNurseRN Burns Quiz) A) Gloves B) Goggles C) Gown D) N-95 mask E) Surgical mask F) Shoe covers G) Hair cover
A, C, E, F, G
A client sustains burns to the anterior portions of both upper extremities, the trunk, and the right leg. The nurse uses the Rule of Nines to estimate the percentage of body surface area burned. Which is the correct percentage? (Kaplan) A) 23% B) 36% C) 45% D) 54%
B) 36% Rationale: Only the front portions of the arms, trunk, and right leg are burned. The calculation is 4.5% for each arm, 18% for the trunk, and 9% for the front of one leg. The Rule of Nines estimates the surface area burned and helps guide treatment decisions, including fluid resuscitation.
A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management? (RegisteredNurseRN Burns Quiz) A) Emergent B) Acute C) Rehabilitative D) Oliguric
B) Acute
While caring for a client who sustained a severe head injury in an accident, the nurse observes that the client is constantly passing urine and is dehydrated. Which would the nurse suspect is the cause of the client's condition? (Evolve) A) Decreased secretion of aldosterone B) Decreased secretion of antidiuretic hormone C) Decreased secretion of parathyroid hormone D) Decreased secretion of atrial natriuretic peptide
B) Decreased secretion of antidiuretic hormone
During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? (RegisteredNurseRN Burns Quiz) A) High fiber, low calories, and low protein B) High calorie, high protein and carbohydrate C) High potassium, high carbohydrate, and low protein D) Low sodium, high protein, and restrict fluids to 1 liter per day
B) High calorie, high protein and carbohydrate Rationale: This type of diet promotes wound healing and meets the caloric demands of the body.
Which action might have led to increased edema in the tissues surrounding chemical burns after a factory explosion? (Evolve) A) Stabilizing the cervical spine B) Lowering burned limbs below the heart C) Brushing dry chemical from skin before irrigation D) Flushing chemical from wound with saline solution
B) Lowering burned limbs below the heart
A client is admitted with a suspected cervical spinal cord injury. What is the nurse's priority action for this client? (Iggy Chp 40 Mastery Questions pg 895) A) Assess cardiac sounds B) Manage the client's airway C) Check oxygen saturation level D) Perform a neurologic assessment
B) Manage the client's airway
What is the best term for the nurse to use when documenting a client's paralysis of both lower extremities? (Iggy Workbook pg 375 #17) A) Paraparesis B) Paraplegia C) Quadriparesis D) Quadriplegia
B) Paraplegia
You're assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene? (RegisteredNurseRN Burns Quiz) A) The nursing assistant elevates the head of the bed above 30 degrees B) The nursing assistant places a pillow under the patient's head C) The nursing assistant places rolled towels under the patient's shoulders D) The nursing assistant covers the patient with sterile linens
B) The nursing assistant places a pillow under the patient's head Rationale: If a patient has severe burns to the neck (head as well) a pillow should not be used under the head because this can cause wound contractions. Instead rolled towels should be placed under the shoulders.
A 35-year-old male patient has superficial partial-thickness burns to the anterior right arm, posterior left leg, and anterior head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned. (RegisteredNurseRN Rule of Nines Quiz) A) 36% B) 9% C) 18% D) 29%
C) 18%
A 66-year-old female patient has deep partial-thickness burns to both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned. (RegisteredNurseRN Rule of Nines Quiz) A) 72% B) 63% C) 81% D) 45%
C) 81%
The nurse is caring for a client with signs of autonomic hyperreflexia. Which factor would the nurse consider as a possible cause? (Evolve) A) Positional vertigo B) Deteriorating myelin sheath C) Distended large intestine D) Fluid volume overload
C) Distended large intestine
A health care provider prescribes mannitol for a client with a head injury. Which mechanism of action is responsible for therapeutic effects of this medication? (Evolve) A) Decreasing the production of cerebrospinal fluid B) Limiting the metabolic requirement of the brain C) Drawing fluid from brain cells into the bloodstream D) Preventing uncontrolled electrical discharges in the brain
C) Drawing fluid from brain cells into the bloodstream
Which type of burn injury should be followed up by scheduling the client for an ECG? (Evolve) A) Flame burn B) Chemical burn C) Electrical burn D) Radiation burn
C) Electrical burn
Your patient with severe burns is due to have a dressing change. You will pre-medicate the patient prior to the dressing change. The patient has standing orders for all the medications below. Which medication is best for this patient? (RegisteredNurseRN Burns Quiz) A) IM morphine B) PO morphine C) IV morphine D) Subcutaneous morphine
C) IV morphine
What is the purpose of placing a child in cervical traction after sustaining a fractured cervical vertebra? (Evolve) A) Hyperextending the neck maintains an open airway B) Flexing the head prevents stretching of the neck muscles C) Immobilizing the area minimizes injury to the spinal cord D) Aligning the body allows for cerebrospinal fluid to encircle the spinal cord
C) Immobilizing the area minimizes injury to the spinal cord
After receiving report on a patient receiving treatment for severe burns, you perform your head-to-toe assessment. On arrival to the patient's room, you note the room temperature to be 75°F. You will: (RegisteredNurseRN Burns Quiz) A) Decrease the temperature by 5-10 degrees to prevent hyperthermia B) Leave the temperature setting C) Increase the temperature to a minimum of 85°F D) Place a heated blanket on the patient
C) Increase the temperature to a minimum of 85°F
What is the nurse's best action when providing care for a client with a traumatic closed head injury, with no history of respiratory problems, when the HCP has prescribed oxygen at 2 L by nasal cannula? (Iggy Workbook pg 384 #25) A) Apply pulse oximetry and administer oxygen to the client if the saturation drops below 90% B) Clarify the prescription because oxygen therapy is unnecessary for this client C) Place the client on oxygen as prescribed because hypoxemia may increase ICP D) Apply the nasal cannula oxygen and wean the client off it over 12-24 hours
C) Place the client on oxygen as prescribed because hypoxemia may increase ICP
The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? (Evolve) A) Decreased rate of glomerular filtration B) Excessive blood loss through the burned tissues C) Plasma proteins moving out of the intravascular compartment D) Sodium retention occurring as a result of the aldosterone mechanism
C) Plasma proteins moving out of the intravascular compartment
After the initial phase of the burn injury, what goals should the nurse establish with the client? (Lippincott Test 16 pg 697 #15) A) Helping the client maintain a positive self-concept B) Promoting hygiene C) Preventing infection D) Educating the client regarding care of the skin grafts
C) Preventing infection
The nurse is caring for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head. Which nursing goal is the priority during the emergent phase of this injury? (Evolve) A) Preventing pain B) Managing leukopenia C) Preventing infection D) Managing fluid loss
C) Preventing infection
A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Which statement explains the nurse's rationale? (Evolve) A) Deep tendon reflexes have been lost B) There is partial transection of the cord C) There is damage above the sixth thoracic vertebra D) Flaccid paralysis of the lower extremities has occurred
C) There is damage above the sixth thoracic vertebra
A client is diagnosed with an incomplete SCI at the 8th cervical nerve (C8). The client and the nurse discuss the client's potential living arrangements after discharge. Which client statement indicates the client understands the limitations due to the SCI? (Kaplan) A) "The wheelchair is only temporary." B) "I will walk again with extensive rehabilitation." C) "Eventually I will be able to feel when my bowels are full." D) "I will be able to drive my car once it is outfitted with hand controls."
D) "I will be able to drive my car once it is outfitted with hand controls."
An older adult client is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" Which is the best response by the nurse? (Evolve) A) "You sound upset, but your HCP knows best. You should do what is prescribed." B) "Your spouse is very capable, but if your burns get infected, a family member can't give you the injections you will need." C) "Your burns are more serious than you think, and we have specially trained people here just to take care of you." D) "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."
D) "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."
A client who sustained burns on the face and upper arms prepares for discharge. The nurse wants to help ease the client's adjustment back into the community. Which of the nurse's actions would be most helpful? (Kaplan) A) Discuss the use of make-up to minimize scars B) Encourage the client to be alone until comfortable with the physical changes C) Persuade the client to view the face and arms in the mirror D) Encourage the client to walk in the hall with family members
D) Encourage the client to walk in the hall with family members
The client with a major burn injury receives TPN. What is the expected outcome of TPN? (Lippincott Test 16 pg 697 #8) A) Correct water and electrolyte imbalances B) Allow the GI tract to rest C) Provide supplemental vitamins and minerals D) Ensure adequate caloric and protein intake
D) Ensure adequate caloric and protein intake
Which health concern has the highest priority for the nurse to monitor for after removing clothing from a client with burn trauma? (Evolve) A) Bradypnea B) Bradycardia C) Hypotension D) Hypothermia
D) Hypothermia
During the emergent phase of burn management, you would expect the following lab values: (RegisteredNurseRN Burns Quiz) A) Low sodium, low potassium, high glucose, low hematocrit B) High sodium, low potassium, low glucose, high hematocrit C) High sodium, high potassium, high glucose, low hematocrit D) Low sodium, high potassium, high glucose, high hematocrit
D) Low sodium, high potassium, high glucose, high hematocrit Rationale: Sodium leaves with the plasma to the interstitial tissue and drops the levels in the blood. High potassium because damaged cells lysis and leak potassium which increases the level in the blood. High glucose occurs due to stress response causing the liver to release glycogen and increase glucose levels. High hematocrit because when the plasma leaves the intravascular system (the fluid) it causes the blood to become more concentrated so hematocrit increases (this will decrease when the patient's fluid is replaced).
Which responses would alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? (Evolve) A) Flaccid paralysis and numbness B) Absence of seating and pyrexia C) Escalating tachycardia and shock D) Paroxysmal hypertension and bradycardia
D) Paroxysmal hypertension and bradycardia
What is the priority focus of prehospital care for a client with a chemical injury burn? (Iggy Workbook pg 196 #35) A) Decontamination B) Fluid balance C) Airway control D) Preventing infection
A) Decontamination
Which is the best action for the nurse to take prior to changing the dressing of a client with a burn injury? (Iggy Workbook pg 197 #38) A) Allow the client to rest and nap for an hour B) Give pain medication 30 minutes prior to dressing change C) Instruct the AP to give the client a complete bath D) Leave the wound open to air for 30 minutes
B) Give pain medication 30 minutes prior to dressing change
Which signs and symptoms indicate to the nurse that a client's TBI will be diagnosed as mild? SATA. (Iggy Workbook pg 384 #22) A) Client appears dazed or stunned B) Loss of consciousness (if any occurred) was between 30-60 minutes C) Nausea and vomiting D) Headache E) Difficulty with gait or balance F) Sensitivity to noise
A, C, D, E, F
A client has a major burn injury. The nurse knows medication is best absorbed by which route for this client? (Kaplan) A) IM B) Orally C) IV D) Topically
C) IV
Which new-onset symptoms indicate to the nurse that a client with a spinal cord injury is experiencing autonomic dysreflexia? SATA. (Iggy Workbook pg 375 #18) A) Sudden hypertension with bradycardia B) Flaccid paralysis C) Blurred vision D) Tachypnea E) Profuse seating of face, neck, and shoulders F) Severe throbbing headache
A, C, E, F
The nurse is monitoring a client with increased ICP. What indicators are the most critical for the nurse to monitor? SATA. (Lippincott Test 11 pg 552 #2) A) Systolic BP B) Urine output C) Breath sounds D) Cerebral perfusion pressure E) Level of pain
A, D
A patient has experienced full-thickness burns to the face and neck. As the nurse, it is a priority to: (RegisteredNurseRN Burns Quiz) A) Prevent hypothermia B) Assess the blood pressure C) Assess the airway D) Prevent infection
C) Assess the airway
The nurse identifies that respiratory paralysis may occur if a client experiences a spinal cord injury above which level? (Kaplan) A) C-6 B) C-5 C) C-4 D) T-1
C) C-4 Rationale: C1-C4 spinal cord injury is the most severe of spinal cord injuries. Respiratory paralysis occurs with a spinal cord injury above C-4.
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? (Lippincott Test 11 pg 553 #9) A) Compress the nares B) Tilt the head back C) Collect the drainage D) Administer an antihistamine for postnasal drip
C) Collect the drainage
The nurse assesses a client who sustained a burn injury. The burn area is red, blistered, and painful. Which classification best describes the burned area? (Kaplan) A) Third degree B) Full thickness C) Deep partial thickness D) Superficial partial thickness
C) Deep partial thickness
The nurse teaches a client diagnosed with a SCI. Which statement best indicates that the client understands the long-term effects of a SCI? (Kaplan) A) "I can't wait to get back on my feet again and repair my bike." B) "I'm going to have to make a lot of adjustments in my life." C) "My friends are expecting me to go camping with them next month." D) "It's weird not to feel things. I'll be glad when that is over."
B) "I'm going to have to make a lot of adjustments in my life."
You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as: (RegisteredNurseRN Burns Quiz) A) 1st Degree (superficial) B) 2nd Degree (partial-thickness) C) 3rd Degree (full-thickness) D) 4th Degree (deep full-thickness)
B) 2nd Degree (partial-thickness)
Select the patient below who is at most risk for complications following a burn: (RegisteredNurseRN Burns Quiz) A) A 42 year old male with partial-thickness burns on the front of the right and left arms and legs B) A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso C) A 36 year old male with full-thickness burns on the front of the left arm D) A 10 year old with superficial burns on the right leg
B) A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso
When should the nurse initiate rehabilitation plans for the client who has severe burns? (Lippincott Test 16 pg 697 #11) A) Immediately after the burn has occurred B) After the client's circulatory status has been stabilized C) After grafting of the burn wounds has occurred D) After the client's pain has been eliminated
B) After the client's circulatory status has been stabilized
Which action does the nurse use to prevent harm by further decreasing ICP when an intubated client with a TBI needs to be suctioned? (Iggy pg 384 #27) A) Providing 100% oxygen before and after each pass of the endotracheal suction catheter B) Aggressively hyperventilating with 100% oxygen before endotracheal suctioning C) Performing oral suctioning often but avoiding endotracheal suctioning D) Obtaining an arterial blood gas sample before suctioning the client
B) Aggressively hyperventilating with 100% oxygen before endotracheal suctioning
What is the initial priority action for the nurse when admitting a client with a cervical spinal cord injury? (Iggy Workbook pg 375 #15) A) Spinal cord immobilization B) Assessment of client's airway, breathing, and circulation C) Evaluation of pulse, BP, and peripheral perfusion D) Checking bodily sites for hemorrhage
B) Assessment of client's airway, breathing, and circulation
What priority complication would the nurse suspect when assessing a client with an electrical burn that has an entrance wound on the right shoulder and an exit wound through the left side of the ribs? (Iggy Workbook pg 196 #33) A) Kidney failure B) Cardiac dysrhythmias C) Gastrointestinal ileus D) Fractured ribs
B) Cardiac dysrhythmias
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F, HR 122, BP 84/42, central venous pressure (CVP) 2, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/hr. Using the SBAR technique for communication, what prescription should the nurse request from the HCP? (Lippincott Test 16 pg 697 #14) A) Furosemide B) Fresh frozen plasma C) IV rate increase D) Dextrose 5%
C) IV rate increase
A patient is in the acute phase of burn management. The patient experienced full-thickness burns to the perineum and sacral area of the body. In the patient's plan of care, which nursing diagnosis is a priority at this time? (RegisteredNurseRN Burns Quiz) A) Impaired skin integrity B) Risk for fluid volume overload C) Risk for infection D) Ineffective coping
C) Risk for infection
The nurse is assessing a client's motor response after brain surgery. The nurse pinches the client's skin to elicit a response and observes the client's arms and legs moving straight out and the feet and toes bend downward. How should the nurse document this response? (Lippincott Test 11 pg 554 #20) A) Flaccid paralysis B) Flexion posturing C) Chronic spastic paralysis D) Extension posturing
D) Extension posturing
The nurse is assessing a client for movement after halo traction placement for a C8 fracture. What should the nurse do to test the client's ability to move? Ask the client to: (Lippincott Test 11 pg 554 #15) A) Shrug shoulders against downward resistance B) Pull arm up from a resting position against resistance C) Straighten arm from a flexed position against resistance D) Grasp the nurse's hands with both hands and squeeze
D) Grasp the nurse's hands with both hands and squeeze
What should the nurse assess the client for during the early phase of burn care? (Lippincott Test 16 pg 697 #12) A) Hypernatremia B) Hyponatremia C) Metabolic alkalosis D) Hyperkalemia
D) Hyperkalemia
What is the nurse's best first action when a client with a spinal cord injury suddenly develops an SpO2 of 92% with stridor, bradycardia with decreased urine output, and a systolic BP of 84? (Iggy Workbook pg 375 #21) A) Apply oxygen at 2 L per nasal cannula B) Place a large-bore IV access C) Insert a urinary catheter D) Notify the Rapid Response Team
D) Notify the Rapid Response Team
Which teaching strategies would the nurse include when instructing clients about how to prevent burn injuries? SATA. (Iggy Workbook pg 196 #36) A) Hot water heaters should be set below 150°F B) Never add a flammable substance to an open flame C) Use sunscreen and protective clothes to avoid sunburn D) Avoid smoking when drinking alcohol or taking drugs that induce sleep E) When space heaters are used, keep flammable objects away from them F) If using home oxygen, do not smoke in the room where oxygen is in use
B, C, D, E, F
The nurse in the Emergency Department assesses a client admitted with splash burns to the chest and arms. The client states the burns occurred when a pot of hot water was knocked off of the stove. The client's skin appears red, moist, and very painful to touch. Fluid filled vesicles are present. Which statement best describes the depth of the burn injury? (Kaplan) A) A first degree thermal burn is present B) A superficial partial-thickness burn is present C) A deep partial-thickness burn is present D) A full-thickness burn is present
C) A deep partial-thickness burn is present
A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client? (Lippincott Test 11 pg 555 #25) A) "I'll get your family." B) "Can you tell me your name and where you live?" C) "I'll bet you are a little confused right now." D) "You're in the hospital. You were in an accident and unconscious."
D) "You're in the hospital. You were in an accident and unconscious."
The nurse provides care for an adult client with deep partial-thickness and full-thickness burns involving 45% of the body surface area. Which information is most concerning to the nurse 24 hours after the client was burned? (Kaplan) A) Urine output of 75 mL/hr with hemachromagens B) A pulse rate of 110 bpm C) A MAP of 75 D) A weight loss of 10% of baseline
D) A weight loss of 10% of baseline
Why does the HCP prescribe a ventilator setting to maintain partial pressure of arterial carbon dioxide (PaCO2) between 35 and 38 mmHg for a client with a TBI? (Iggy Workbook pg 384 #23) A) Lower levels of arterial carbon dioxide are essential for gas exchange B) Carbon dioxide is a waste product that must be eliminated from the body C) Lower levels of arterial carbon dioxide facilitate brain oxygenation D) Carbon dioxide is a vasodilator that can cause increased ICP
D) Carbon dioxide is a vasodilator that can cause increased ICP
The _____________ layer of the skin helps regulate our body temperature. (RegisteredNurseRN Burns Quiz). A) Epidermis B) Dermis C) Hypodermis D) Fascia
C) Hypodermis
The nurse is assessing a client with increasing ICP. The nurse should notify the HCP about which early change in the client's condition? (Lippincott Test 11 pg 553 #12) A) Widening pulse pressure B) Decrease in the pulse rate C) Dilated, fixed pupils D) Decrease in level of consciousness
D) Decrease in level of consciousness
Which activity should the nurse encourage the client to avoid when there is a risk for increased ICP? (Lippincott Test 11 pg 554 #17) A) Deep breathing B) Turning C) Coughing D) Passive ROM exercises
C) Coughing
The nurse monitors a client who experienced partial-thickness and full-thickness burns over the lower extremities 24 hours ago. Which signs does the nurse anticipate during this phase of burn injury? (Kaplan) A) Decreased urinary output B) Increased BP C) Decreased potassium and sodium levels D) Decreased hematocrit level
A) Decreased urinary output
The nurse provides care for a client who has full-thickness burns. The nurse understands the Rule of Nines is used to help determine the treatment the client will receive. Which explanation best describes the Rule of Nines as applied to burns? (Kaplan) A) Each arm constitutes 9% of body surface area B) Fluid resuscitation is increased by 9% every hour C) The amount of hourly urine output should be 9% of hourly IV intake D) For every % of body surface area burned, the client's chance of survival is decreased by 9
A) Each arm constitutes 9% of body surface area
As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for: (RegisteredNurseRN Burns Quiz) A) Hemoglobin and myoglobin B) Free iron and white blood cells C) Protein and red blood cells D) Potassium and Urea
A) Hemoglobin and myoglobin
A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the HCP? (Iggy Chp 40 pg 884) A) Purulent drainage from the pin sites on the client's forehead B) Painful pressure injury under the collar C) Inability to move legs or feet D) Oxygen saturation of 95% on room air
A) Purulent drainage from the pin sites on the client's forehead
The client has a sustained increased ICP of 20 mmHg. Which client position would be most appropriate? (Lippincott Test 11 pg 554 #13) A) The head of the bed elevated 15-20 degrees B) Trendelenburg's position C) Left Sims' position D) The head elevated on two pillows
A) The head of the bed elevated 15-20 degrees
Which assessment findings would the ED nurse expect when a client has a smoke-related inhalation injury? SATA. (Iggy Workbook pg 196 #34) A) Soot around the nose or mouth B) Singed nasal hairs C) Hoarseness of speech D) Shortness of breath E) Cherry red skin F) Cough
A, B, C, D, F
Which actions will the nurse take when caring for a client with a spinal cord injury who is experiencing autonomic dysreflexia? SATA. (Iggy Workbook pg 375 #19) A) Raise the head of the bed B) Check the client's bladder for distention C) Place a condom catheter on male clients as necessary D) Give nifedipine or nitrate as prescribed E) Monitor BP every 10-15 minutes F) Check the client for fecal impaction
A, B, D, E, F
Which factors increase the risk of complications from a burn injury in an older adult client? SATA. (Iggy Workbook pg 197 #40) A) Slower healing time B) Thinner skin C) Increased inflammatory response D) Increased pulmonary compliance E) Medical conditions such as diabetes F) Increased immune response
A, B, E
Which are priorities of care when providing care for a client with a burn injury during the emergent phase? SATA. (Iggy Workbook pg 197 #39) A) Securing the airway B) Maintaining nutrition status C) Supporting circulation and perfusion D) Maintaining body temperature E) Keeping client comfortable with analgesics F) Psychosocial adjustment
A, C, D, E
A client has an increased ICP of 20 mmHg. What should the nurse do next? (Lippincott Test 11 pg 553 #11) A) Give the client a warming blanket B) Administer low-dose barbiturates C) Encourage the client to take deep breaths to hyperventilate D) Restrict fluids
C) Encourage the client to take deep breaths to hyperventilate
During the emergent (resuscitative) phase of a burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? (Lippincott Test 16 pg 696 #3) A) Serum creatinine level of 2.5 B) Little fluctuation in daily weight C) Hourly urine output of 60 mL D) Serum albumin level of 3.8
A) Serum creatinine level of 2.5
The nurse provides care for a client diagnosed with a SCI following an accident. The client was stable immediately after admission. Eight hours later the nurse notices that the client has clear, blood-tinged fluid leaking from the right ear. Which problem is the nurse most concerned about? (Kaplan) A) The fluid may be cerebrospinal fluid B) The client may be uncomfortable with this discharge C) There may be something in the client's ear canal D) The eardrum may have ruptured and be leaking fluid
A) The fluid may be cerebrospinal fluid
The nurse provides care for a client diagnosed with severe TBI. The client has been placed on fluid restriction. The client has an intraventricular monitor in place and the ICP reading is 25. What is the rationale for the fluid restriction? (Kaplan) A) To decrease cerebral edema B) To decrease peripheral edema C) To decrease the need for suctioning D) To decrease the risk of respiratory complications
A) To decrease cerebral edema
The nurse provides care for an adult client during the resuscitation phase of a severe burn injury. Which assessment finding indicates to the nurse that the amount of intravenous fluid replacement needs to be increased? (Kaplan) A) Urine output of 15 mL/hr B) Engorged neck veins C) Electrolytes within normal limits D) Decreased core body temperature
A) Urine output of 15 mL/hr
There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported immediately to a burn center for treatment? SATA. (Lippincott Test 16 pg 696 #1) A) An 8-year-old with third-degree burns over 10% of the body surface area (BSA) B) A 20-year-old who inhaled the smoke of the fire C) A 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the BSA) D) A 30-year-old with second-degree burns on the back of the left leg (about 9% of the BSA) E) A 40-year-old with second-degree burns on the right arm (about 10% of the BSA)
A, B, C
Which questions are essential for the nurse to ask when getting an accurate history of a client's traumatic brain injury (TBI) SATA. (Iggy Workbook pg 383 #21) A) When, where, and how did the injury occur? B) Did the client lose consciousness? If so, for how long? C) Was drug or alcohol consumption related to the TBI? D) Does the client have a history of seizure disorders? E) Precisely how did the older client fall to cause the TBI? F) Has there been a change in the client's level of conscious?
A, B, C, D, E, F
Which questions will the nurse be sure to ask EMS when an unconscious client with a cervical spinal cord injury is brought into the ED? SATA. (Iggy Workbook pg 375 #13) A) What was the location and position of the client immediately after the injury? B) Has the family been notified for permission to begin treatment? C) What symptoms occurred immediately after the injury and what changes have occurred since then? D) What type of immobilization equipment was used at the site and were there problems with transport? E) What treatments were given at the site of the injury and during transport? F) Does the client have a history of any respiratory problems or difficulties?
A, C, D, E, F
Which actions will the nurse include when caring for a trauma client in the ED for whom the health care provider prescribes spinal precautions? SATA. (Iggy Workbook pg 385 #28) A) Avoiding neck flexion with a pillow or a roll B) Placing client on bedrest with bathroom privileges C) Using log roll procedure when repositioning the client D) Avoiding reverse Trendelenburg positioning E) Using a hard, rigid cervical collar to maintain cervical spine precautions F) Avoiding thoracic or lumbar flexion
A, C, E, F
A client suffers a full thickness burn injury. The nurse provides care for the client during the emergent phase. The nurse understands which finding is expected during this phase? (Kaplan) A) Increased BP B) Decreased urine output C) Hypokalemia D) Decreased pulse
B) Decreased urine output
The nurse determines a client has a deep partial thickness burn injury of the back. Which is the best initial nursing action? (Kaplan) A) Break the blisters with a scalpel using sterile technique B) Gently clean the area and determine the extent of the burn C) Apply a thin layer of petroleum jelly to the area D) Wrap the area snugly with sterile gauze
B) Gently clean the area and determine the extent of the burn
Which statement best describes hyperflexion as a cause of a client's spinal cord injury? (Iggy Workbook pg 374 #12) A) Hyperflexion occurs most often in vehicle collisions in which the vehicle is struck from behind or during falls when the client's chin is struck B) Hyperflexion is a sudden and forceful acceleration (movement) of the head forward, causing extreme flexion of the neck C) Hyperflexion results from diving accidents, falls on the buttocks, or a jump in which a person lands on their feet D) Hyperflexion results from injuries that are caused by turning the head beyond the normal range
B) Hyperflexion is a sudden and forceful acceleration (movement) of the head forward, causing extreme flexion of the neck
In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? (Lippincott Test 16 pg 698 #18) A) Oral analgesics such as ibuprofen or acetaminophen B) IV opioids C) IM opioids D) Oral anti-anxiety agents such as Lorazepam
B) IV opioids
The nurse administers mannitol to the client with increased ICP. Which parameter requires close monitoring? (Lippincott Test 11 pg 554 #14) A) Muscle relaxation B) Intake and output C) Widening of the pulse pressure D) Pupil dilation
B) Intake and output
A client diagnosed with a cervical SCI reports a pounding headache and blurred vision. The nurse assesses the client and notes the BP is 210/110, HR is 50, the client's face and chest are flushed, and the urinary catheter is kinked. Which action does the nurse take first? (Kaplan) A) Flush the indwelling urinary catheter with sterile saline B) Raise the head of the bed 45-60 degrees C) Check the BP on the opposite arm D) Provide reassurance and attempt to calm the client
B) Raise the head of the bed 45-60 degrees
The nurse provides care for an adolescent client diagnosed with a superficial, partial-thickness burn. Which finding does the nurse expect? (Kaplan) A) The client's skin has very painful blisters B) The client's skin is red and tender with no blisters C) The client's skin has white and dry burns with no blisters D) The client reports decreased sensation to the burn area that does not blanch with pressure
B) The client's skin is red and tender with no blisters
Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has: (Lippincott Test 16 pg 697 #13) A) Electrical burns of the hands and arms caused by arrhythmias B) Thermal burns to the head, face, and airway resulting in hypoxia C) Chemical burns on the chest and abdomen D) Secondhand smoke inhalation
B) Thermal burns to the head, face, and airway resulting in hypoxia
The nurse provides care for a school-age client with a TBI. Which symptoms best indicated increased ICP? (Kaplan) A) Headache, crying, sensitivity to loud noised and bright lights B) Widening pulse pressure, slowed respirations, bradycardia C) Hypotension, cyanosis, tachycardia D) Increased temperature, increase in respirations, shaking
B) Widening pulse pressure, slowed respirations, bradycardia
A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his pregnant wife to the hospital. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? SATA. (Lippincott Test 11 pg 552 #4) A) Find a television so the client can view the football game B) Determine if the client's pupils are equal and react to light C) Ask the client if he has a headache D) Arrange for the client to be with his wife and baby E) Administer a sedative
B, C
The nurse has established a goal to maintain ICP within normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? SATA. (Lippincott Test 11 pg 552 #1) A) Encourage the client to cough and expectorate secretions B) Elevate the head of the bed by 15-20 degrees C) Contact the HCP if ICP is > 28 D) Monitor the neurologic status using the Glasgow Coma Scale E) Stimulate the client with active ROM exercises
B, C, D
A client diagnosed with a spinal cord injury at T-1 reports a pounding headache and feeling flushed. The nurse notes the client's BP is 240/130, HR is 56, and the client's head and chest are diaphoretic. What is the best action for the nurse to take? (Kaplan) A) Tell the client to take slow, deep breaths B) Encourage the client to lie down and remain still C) Assess patency of the client's indwelling urinary catheter D) Administer an analgesic for the headache
C) Assess patency of the client's indwelling urinary catheter
The nurse describes the emergency plan of care when providing care for a client suspected of having a SCI. Which statement indicates the nurse requires additional teaching? (Kaplan) A) "Only move the client when there are enough people to immobilize the spine during transfer." B) "The neck should be stabilized in a neutral position with a neck brace when moving the client." C) "The head should be held in gentle traction to prevent further injury to the cervical spine." D) "The client should be strapped to a spinal board that has straps to secure the head, torso, and legs."
C) "The head should be held in gentle traction to prevent further injury to the cervical spine."
What would be the nurse's best action when a client with a burn injury develops a brassy cough, increased difficulty swallowing, and progressive hoarseness? (Iggy Workbook pg 196 #37) A) Place the client on continuous pulse oximetry B) Instruct the AP to check vital signs every 30 minutes C) Activate the Rapid Response Team D) Establish a second IV access
C) Activate the Rapid Response Team
A client who had a serious head injury with increased ICP is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will: (Lippincott Test 11 pg 554 #18) A) Exhibit no further episodes of short-term memory loss B) Be able to return to his construction job in 3 weeks C) Actively participate in the rehabilitation process as appropriate D) Be emotionally stable and display pre-injury personality traits
C) Actively participate in the rehabilitation process as appropriate
A client is brought to the ED by a family member. The client has full-thickness burns to the head, neck, chest, and right upper extremities. Which nursing intervention is the priority? (Kaplan) A) Insert an IV catheter B) Cover burns with a sterile dressing C) Establish and maintain a patent airway D) Administer Lactated Ringer at 200 mL/hr
C) Establish and maintain a patent airway
A client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. The client's BP is 190/110. What is the nurse's priority action at this time? (Iggy Chp 40 pg 882) A) Perform a bladder assessment B) Insert an indwelling urinary catheter C) Place the patient in a sitting position D) Turn on a fan to cool the patient
C) Place the patient in a sitting position
A client was involved in a motorcycle accident and is diagnosed with a SCI and fracture of T-12. Once the client is stabilized, the nurse plans for the client's long-term care needs. Which plan is most appropriate? (Kaplan) A) The client will use an electric wheelchiar with breath control, chin control, or voice activation B) The client will use hand splints for feeding, sliding board for wheelchair transfer, and arm slings over bed C) The client will have wheelchair independence and possible ambulation with long leg braces and crutches D) The client will have independent ambulation with short leg braces with or without crutches
C) The client will have wheelchair independence and possible ambulation with long leg braces and crutches Rationale: Clients with SCI from T5-L2 can have total wheelchair dependence because they can have partial to good trunk stability. If the injury is T-12 or below, limited ambulation with long leg braces and crutches can be obtained.
When teaching a community group about burn prevention, which education will the nurse include? A) "Have a smoke detector in one central spot in the home." B) "If you use home oxygen, turn it down when you are smoking." C) "Set your water heater temperature below 160° F." D) "Plan several ways of escape from the home in case the primary exit is blocked."
D) "Plan several ways of escape from the home in case the primary exit is blocked."
What is the nurse's best interpretation when assessing a client with a TBI and finding that the right pupil appears more ovoid in shape than the left? (Iggy Workbook pg 384 #26) A) An ovoid pupil is not significant unless the client has severe hypertension, changes in the level of consciousness, and respiratory distress B) An ovoid pupil is assumed to signal brain herniation in progress with a poor prognosis C) An ovoid pupil is considered a normal variation for a small percentage of clients who sustain minor head injuries D) An ovoid pupil is regarded as the mid-stage between a normal pupil and a dilated pupil and must be reported immediately
D) An ovoid pupil is regarded as the mid-stage between a normal pupil and a dilated pupil and must be reported immediately
The nurse provides care for a client diagnosed with a spinal cord injury at the level of T-3. The client reports a pounding headache and nasal congestion. The nurse notes the client has profuse sweating from the forehead. Which action does the nurse take first? (Kaplan) A) Administers an analgesic to relieve the headache B) Places the client in Trendelenburg position C) Administers a prescribed stool softener D) Checks the indwelling urinary catheter and tubing for kinks
D) Checks the indwelling urinary catheter and tubing for kinks Rationale: Presence of an indwelling urinary catheter can cause stimulation of the bladder and trigger autonomic dysreflexia (AD) for the client with a high level spinal cord injury. If no indwelling urinary catheter is present, the nurse should check for bladder distention and catheterize immediately. A UTI may also precipitate an episode of AD.
A client was admitted to the hospital unit a few minutes ago with a new diagnosis of right hemiparesis and aphasia, which resulted from a TBI. Which of the following interventions is a priority for the client at this time? (Iggy Chp 41 Mastery Questions pg 927) A) Contact the physical therapist to plan care to increase the client's mobility B) Contact the occupational therapist to assess the client's ADL ability C) Contact the unit social worker to talk with the family about the patient's discharge D) Contact the speech-language pathologist to schedule a swallowing study
D) Contact the speech-language pathologist to schedule a swallowing study
