Ndee

Lakukan tugas rumah & ujian kamu dengan baik sekarang menggunakan Quizwiz!

A school-aged child is brought to the emergency department with partial- and full-thickness burns of the lower extremities. The practitioner writes multiple prescriptions. What is the nurse's priority intervention? Question options: a) Administering oxygen. b) Inserting a urinary catheter. c) Giving prescribed pain medication. d) Starting an intravenous line with a large bore catheter.

Starting an intravenous line with a large bore catheter.

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics? Question options: a) Oral. b) Topical. c) Intravenous. d) Intramuscular.Topical.

Topical.

A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aide station. The nurse encourages the client to seek medical attention but the client refuses. The nurse advises the person to go to a health care provider if:

Urinary output decreases.

A client who is being discharged with severe facial scarring from burns tells the nurse, "I've saved some oxycodone, and when I get home I'm going to take all of them. Don't tell anyone." What is the best response by the nurse? Question options: a) "Are you going to kill yourself?" b) "You don't want me to tell anyone?" c) "Are you in a lot of pain right now?" d) "Do you know that too much oxycodone is dangerous?"

"Are you going to kill yourself?"

A health care provider prescribes a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation should the nurse provide as to why the client needs to follow this diet? Question options: a) "The use of salt probably contributed my disease." b) Excess weight will be gained if sodium is not limited." c) "The loss of excess sodium and potassium in the urine requires less renal stimulation." d) "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."

"Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."

Immediately after a bilateral adrenalectomy a client is receiving corticosteroids that are to be continued after discharge from the hospital. The nurse eval;uates a need for further teaching when the client states: Question options: a) "I need to have a periodic tests of my blood for glucose." b) "I must take the pills with meals while I have food in my stomach." c) "I am glad that I only have to take the medication once a day." d) "I should tell the doctor if I am overly restless or have trouble sleeping."

"I am glad that I only have to take the medication once a day."

A 16-year-old client with full-thickness burns of the entire right arm states, "I'll never be able to use my arm again. I'll be scarred forever." What is the best initial response by the nurse? Question options: a) "Think about how lucky you are. You're still alive." b) "Minimizing scarring is the goal of the entire professional." c) Being worried is understandable, but it's really too early to tell." d) "Try not to worry. Concentrate on doing your rang-of-motion exercises."

"Minimizing scarring is the goal of the entire professional."

A client who has acromegaly and insulin-dependent diabetes undergoes a hypophysectomy. The nurse identifies that further teaching about the hypophysectomy is necessary when the client states. " I know I will: Question options: a) "Be sterile for the rest of my life." b) "Require larger doses of insulin than I did before the surgery." c) "Have to take cortisone or similar drug for the rest of my life." d) "Have to take thyroxine on a similar medication for the rest of my life."

"Require larger doses of insulin than I did before the surgery."

A female client receiving cortisone therapy for adrenal insufficiency expresses concern about why she is developing facial hair. How should the nurse respond? Question options: a) "Its just another sign of illness." b) "Do not worry because it will disappear with therapy." c) "This is not important as long as you are feeling better.' d) "The drug contains a hormone that causes male characteristics."

"The drug contains a hormone that causes male characteristics."

A 4-year-old child is admitted with burns over the entire right arm and the anterior and posterior aspects of both legs. Using the percentage of total body surface area (TBSA) that was burned, the nurse estimates that the TBSA affected is approximately: Question options: a) 36% b) 41% c) 47% d) 52%

41%

The nurse uses the rule of nines to estimate the percentage of the burn surface area on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the left leg. The nurse estimates the surface area to be? Question options: a) 18 b) 34 c) 55 d) 73

55

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful according to the client and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, the nurse should administer the medication: Question options: a) 15 minutes before the dressing change. b) 60 minutes before the dressing change. c) Along with a stool softener each time it is administered. d) Only if the client rates the pain betwenn 8 and 10 on the pain scale.

60 minutes before the dressing change.

A client is admitted after incurring electrical burns to both hands while playing golf during a lightning storm. When assessing the entrance and exit wounds, the nurse considers that electrical injury: Question options: a) Causes severe nervous tissue destruction along a path of least resistance. b) Results in severe tissue destruction when the burn is incurred by direct current. c) Causes a line of destruction beginning at the grounding point to the point of contact. d) Results in visible dermal wounds that denote the internal electrical current destruction.

Causes severe nervous tissue destruction along a path of least resistance.

The parents of a young man suspected of having Cushing syndrome expresses anxiety about their son's condition. What should the nurse tell the parents to help them better understand the illness? Question options: a) He will need to take exogenous steroidsa for several months. b) His condition will indicate improvement when he gains weight. c) He may have mood swings or depression as a result of his illness. d) His physical changes are permanent but may improve with therapy.

He may have mood swings or depression as a result of his illness.

The nurse expects the diagnostic studies of a client with Cushing's syndrome to indicate: Question options: a) Moderately increased serum potassium levels. b) Increased numbers of eosinophils in the blood. c) High levels of 17-ketosteroids in 24 hour urine test. d) Low levels of adenocorticotropic hormone (ACTH).

High levels of 17-ketosteroids in 24 hour urine test.

Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? Select all that apply. Question options: 1) Lability of mood. 2) Slow wound healing. 3) A decrease in the growth of hair. 4) Ectomorphism with a moon face. 5) An increased resistance to bruising.

Lability of mood and slow wound healing.

A client is admitted to the hospital with a diagnosis of Cushing syndrome. When performing an assessment, the nurse should take into consideration that the client will most likely exhibit signs of: Question options: a) Hyperkalemia and edema. b) Hypotension and sodium loss. c) Muscle wasting and hypoglycemia. d) Muscle weakness and frequent urination.

Muscle weakness and frequent urination.

A client is brought to the emergency department with deep partial-thickness burns on the face and full-thickness burns on the neck, entire anterior chest, and one arm. To assess for heat inhalation, the nurse first should observe for: Question options: a) Changes in the chest x-ray findings. b) Sputum that contains particles of blood. c) Nasal discharge containing carbon particles. d) Changes in arterial blood gases consistent with acidosis.

Nasal discharge containing carbon particles.

A client with a primary brain tumor has developed a syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? Select all that apply. Question options: Nausea and vomiting. Hyperthermia. Bradycardia. Increased weight Decreased serum sodium. Decreased level of consciousness.

Nausea and vomiting, increased weight, decreased serum sodium, and decreased level of consciousness.

A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply. Question options: 1) Oliguria. 2) Siezures. 3) Vomiting 4) Polydipsia. 5) Polyphagia.

Oliguria, seizures, and vomiting.

A nurse is caring for an adult client with acromegaly. what clinical manifestation does the nurse expect the client to exhibit? Question options: a) Prominent jaw. b) Decreased pulse. c) Increased height. d) Increased sodium

Prominent jaw.

A nurse understands that a temporary heterograft (pig skin) is used to treat burns because this graft: Question options: a) Debrides necrotic tissue b) Promotes rapid epithelialization. c) Is sutured in place for better adherence d) Will be used concurrently with a topical antimicrobial

Promotes rapid epithelialization.

A nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify? Question options: Retention of sodium and water. Hypotension and a rapid thready pulse. Increased fatty deposition in the extremities. Hypoglycemic episodes in the early morning.

Retention of sodium and water.

The nurse is collecting information about a client who underwent a transsphenoidal removal of pituitary tumor. Which findings should indicate to the nurse that the client is experiencing DI? Select all that apply. Question options: 1) Serum osmolality 310 mOsm/kg. 2) Weight increased 2 kgg in 24 hours. 3) Experiencing an extreme thirst. 4) Urine output 4200 mL in 24 hours. 5) BP averaging 164/92 mm Hg or higher.

Serum osmolality 310 mOsm/kg, Experiencing an extreme thirst, and Urine output 4200 mL in 24 hours.

A 3-year-old child is admitted to the burn unit with partial- and full-thickness burns over 30% of the body. For what complication should the nurse assess the child during the first 48 hours? Question options: a) Shock. b) Pneumonia. c) Contractures. d) Hypertension.

Shock.

A client with burns asks the nurse about which type of topical antimicrobial will be prescribed. The nurse recalls that: Question options: a) Silver sulfadiazine (Silvadene) is easy to apply and has good bactericidal action but it can depress granulocyte formation. b) Mafenide acetate (Sulfamylon) causes no side effects and is effective for both gram-positive and gram-negative organisms. c) Neomycin (Cortisporin) is a strong bactericidal agent effective against most organisms with few toxic side effects. d) Silver nitrate paste is a dry dressing with strong bacteriostatic properties, and clients respond quickly to this medication.

Silver sulfadiazine (Silvadene) is easy to apply and has good bactericidal action but it can depress granulocyte formation.

A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. what should the nurse do? Question options: a) Start the time of the test after discarding the first voiding. b) Discard the last voiding in the 24-hour time period for the test. c) Insert a urinary retention catheter to promote the collection of urine. d) Strain the urine following each voiding before adding the urine to the container.

Start the time of the test after discarding the first voiding.

A firefighter is admitted to the emergency department with severe dermal and inhalation burns. On assessment, a nurse identifies tachycardia, tachypnea, and dyspnea. What term should the nurse document in the medical record when the following is heard on auscultation of the lungs of this client? Listen to the audio. Question options: a) Stridor. b) Rhonchi. c) Crackles. d) Wheezes.

Stridor.

A client who sustained serious burns now has a stress ulcer. When caring for this client, what clinical indicators of shock should the nurse immediately report to the health care provider? Select all that apply. Question options: 1) Weakness. 2) Diaphoresis 3) Tachycardia. 4) Cold extremities. 5) Flushed skin tone.

Weakness, Diaphoresis, Tachycardia, and Cold extremities.

A client on prolonged cortisone therapy for adrenal insufficiency is being discharged. Which side effects should the nurse teach the client and family to expect? Select all that apply. Question options: 1) Oliguria. 2) Anorexia. 3) Weakness. 4) Moon Face 5) Weight gain. 6) Nervousness.

Weakness, moon face, and weight gain.

The nurse stops at an accident scene to administer emergency care for a person who has sustained partial- and full-thickness burns to the chest, right arm, and upper legs as the result of a car fire. What should the nurse do first when caring for this person? Question options: a) Cover the person with a warm blanket. b) Wrap the person is clean, dry sheet. c) Apply sterile dressings to burned areas to prevent contamination. d) Remove the person's clothing to prevent further trauma.

Wrap the person is clean, dry sheet.

A client is admitted with a diagnosis of chronic adrenal insufficiency. When assigning a room, which roommate should be avoided because of the newly admitted client's condition? Question options: a) Young adult client with pneumonia. b) Adolescent client with a fractured leg. c) Older adult client who had a brain attack. d) Middle-aged client who has cholecystitis.

Young adult client with pneumonia.

A client sustains severe burns over 40% of the surface area of the body. The nurse is assigned to care for the client during the first 48 hours after the injury. What clinical finding does the nurse anticipate if the client develops water intoxication? Question options: a) Sooty-colored sputum. b) Frothy pink-tinge sputum. c) Disorientation with twitching. d) Urine output of 25 mL/hr.

Disorientation with twitching

When a nurse is evaluating the condition of a client with burns of the upper body, a sign that indicates potential respiratory obstruction is: Question options: a) Deep breathing. b) Hoarse quality of voice. c) Pink-tinged frothy sputum. d) Rapid abdominal breathing.

Hoarse quality of voice.

A client with a tentative diagnosis of Cushing syndrome has an increased cortisol level. For what response should the nurse assess this client? Question options: a) Hypovolemia. b) Hyperkalemia. c) Hypoglycemia. d) Hypernatremia.

Hypernatremia

A nurse is caring for a client with a diagnosis of Cushing's syndrome. What is the most common cause of Cushing's syndrome that the nurse should consider before assessing this client for physiological responses? Question options: a) Pituitary hypoplasia. b) Hyperplasia of the adrenal cortex. c) Deprivation of adrenocortical hormones d) Insufficient adrenocorticotropic hormone (ACTH) production.

Hyperplasia of the adrenal cortex.

A client who is suspected of having Cushing syndrome is admitted to the hospital. The nurse plans to monitor this client for: Question options: a) Hypokalemia. b) Hypovolemia. c) Hypocalcemia. d) Hyponatremia.

Hypokalemia.

After surgical clipping of cerebral aneurysm, a client develops the syndrome of inappropriate of antidiuretic hormone (SIADH). The nurse expects that manifestations of excessive levels of antidiuretic hormone are: Question options: a) Increases blood urea nitrogen (BUN) and hypotension. b) Hyperkalemia and poor skin turgor. c) Hyponatremia and decreased urine output. d) Polyuria and increased specific gravity of urine.

Hyponatremia and decreased urine output.

A nurse is providing postoperative care for a client one hour after the client had an adrenalectomy. Maintenance steroid therapy has not begun yet. The nurse should monitor the client for which complication? Question options: a) Hypotension. b) Hyperglycemia. c) Sodium retention. d) Potassium excretion.

Hypotension.

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data? Question options: a) Weights everyday. b) Urinary output every hour. c) Blood pressure every 15 minutes. d) Extent of peripheral edema every 4 hours.

Urinary output every hour.

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which manifestations of excessive levels of ADH should the nurse asses the client? Select all that apply. Question options: Polyuria. Weight gain Hypotension. Hyponatremia. Decreased urine specific gravity

Weight gain and hyponatremia.

The nurse understands that the action of antidiuretic hormone is to: Question options: a) Reduce red blood volume. b) Decrease water loss in urine. c) Increase urine output. d) Initiate the thirst mechanism.

Decrease waster loss in urine.

Which clinical manifestation should a nurse expect a client with diabetes insipidus to exhibit? Question options: a) Increase blood glucose. b) Decreased serum sodium. c) Increased specific gravity. d) Decreased urine osmolarity.

Decreased urine osmolarity.

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone. For which manifestation of excessive levels of antidiuretic hormone (ADH) should the nurse assess? Question options: Increased blood urea nitrogen (BUN). Decreased urine output. Decreased specific gravity. Increased serum sodium level.

Decreased urine output

A client is admitted to the hospital with partial- and full-thickness burns of the chest sustained in a house fire. What is the nurse's priority concern? Question options: a) Limited physical mobility caused by bedrest. b) Inadequate gas exchange because of smoke inhalation. c) Susceptibility to infection as a result of tissue trauma. d) Decreased fluid volume because of inadequate fluid intake.

Inadequate gas exchange because of smoke inhalation.

After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For whivh clinical indicators should the nurse monitor the client? Select all that apply. Question options: Polyuria. Insomnia. Bradycardia. Increased weight. Decreased serum sodium. Decreased level of consciousness.

Increased weight, decreased serum sodium, and decreased level of consciousness.

The nurse applies mafenide acetate cream (Sulfamylon) to a client's burns as prescribed by the health care provider. The nurse teaches the client that the purpose of the medication is to: Question options: 1) Inhibit bacterial growth. 2) Relieve pain from the burn. 3) Prevent scar tissue formation. 4) Provide chemical debridement.

Inhibit bacterial growth.

Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is nothing by mouth (NPO) is complaining of severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do? Question options: a) Give the client orange juice by mouth. b) Offer the client 4 oz of water by mouth. c) Increase the client's intravenous (IV) flow rate. d) Moisten the client's lips with a wet 4 x 4 gauze.

Moisten the client's lips with a wet 4 x 4 gauze.

A client undergoes pituitary surgery via transsphenoidal route. Which foods should the nurse instruct the client to avoid after surgery? Select all that apply. Question options: Toast. Celery. Shellfish. Grapefruit. Aged cheese.

Toast, Celery.

A client is scheduled for a bilateral adrenalectomy. Before surgery, steroids are administered to the client. What does the nurse determine is the reason for the steroids? Question options: a) Foster accumulation of glycogen in the liver. b) Increases the inflammatory action to promote scar formation. c) Facilitate urinary excretion od salt and water following surgery. d) Compensate for sudden lack of these hormones following surgery.

Compensate for sudden lack of these hormones following surgery.

The nurse is providing care for a client with small-cell carcinoma of the lung that develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What clinical findings correspond with the secretion of antidiuretic hormone (ADH)? Select all that apply. Question options: 1) Edema 2) Polyuria. 3) Bradycardia. 4) Hypotension. 5) Hyponatremia.

Edema and hyponatremia.

Fludrocortisone (Florinef) is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse teach the client to report? Select all that apply. Question options: 1) Edema. 2) Rapid weight gain. 3) Fatigue in the afternoon. 4) Unpredictable changes in mood 5) Increased frequency of urination

Edema and rapid weight gain.

A nurse is assessing a client with a diagnosis of diabetes insipidus. For which signs indicative of diabetes insipidus should the nurse assess the client? Select all that apply. Question options: 1) Excessive thirst. 2) Increased blood glucose. 3) Dry mucous membranes. 4) Increased blood pressure. 5) Decreased serum osmolarity. 6) Decreased urine specific gravity

Excessive thirst, Dry mucous membranes, and Decreased urine specific gravity.

A client with coronary artery disease and hypertension has been diagnosed with diabetes insipidus (DI). Why should the nurse conclude that treatment with antidiuretic hormone (ADH) is contraindicated for this client? Question options: Fluid overload and elevated BP could occur. Volume depletion and decreased BP could occur. Overstimulation and agitation could occur. Hypercalciuria and renal calculi could occur.

Fluid overload and elevated BP could occur.

A nurse is caring for a newly admitted client with a diagnosis of Cushing syndrome. Why should the nurse monitor this client for clinical indicators of diabetes mellitus? Question options: a) Cortical hormones stimulate rapid weight loss. b) Tissue catabolism results in a negative nitrogen balance. c) Glucocorticoids accelerate the process of gluco-neogenesis. d) Excessive adrenocorticotropic hormone (ACTH) secretion damages pancreatic tissue.

Glucocorticoids accelerate the process of gluco-neogenesis.

A nurse is transferring a client with a diagnosis of pheochromocytoma from a bed to a chair. What si the most important nursing intervention associated with this procedure for this client? Question options: a) Supporting the client on the weak side. b) Ensuring that the chair is close to the client's bed. c) Placing sturdy shoes with rubber soles on the client's feet. d) Having the client on the side of the bed for a few minutes before the transfer.

Having the client on the side of the bed for a few minutes before the transfer.

A nurse administers the drug desmopressin acetate (DDAVP) to a client with diabetes insipidus (DI). What should the nurse monitor to evaluate the effectiveness of the drug? Question options: a) Arterial pH. b) Intake and output c) Fasting serum glucose. d) Pulse and respiratory rates.

Intake and output.

The nurse provides care to the client with diabetes insipidus (DI) following head injury by: Select all that apply. Question options: 1) Providing adequate fluids within easy reach. 2) Reporting an increasing urine specific gravity. 3) Administering prescribed demeclocycline (Declomycin). 4) Assessing for and reporting changes in neurological status. 5) Monitoring for constipation, weight loss, hypotension and tachycardia.

Providing adequate fluids within easy reach, Assessing for and reporting changes in neurological status, and Monitoring for constipation, weight loss, hypotension and tachycardia.

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? Select all that apply. Question options: 1) Diplopia. 2) Dysphagia. 3) Tachypnea 4) Bradycardia 5) Hypotension

Tachypnea and hypotension.

After stabilization of an acute adrenal insufficiency (Addisonian crisis), intravenous medications are decreased gradually, and the client now is receiving hydrocortisone by mouth. What instruction should the nurse include when performing discharge teaching? Question options: a) Eat a diet high in sodium. b) Take the medication with food. c) Maintain the same dose indefinitely. d) Eliminate a dose if side effects occur.

Take the medication with food.


Set pelajaran terkait

APUSH Chapter 8 Benjamin Franklin Essay Question

View Set

Genetics Exam 4 Chapter 16 Human Ancestry and Evolution

View Set

Intro to Business- Exam One (Set Two)

View Set