Exam #4

The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply. 1. Restrict fluids per healthcare provider order. 2. Assess level of consciousness every two (2) hours. 3. Provide an atmosphere of stimulation. 4. Monitor urine and serum osmolality. 5. Weigh the client every three (3) days.

1. Restrict fluids per healthcare provider order. 2. Assess level of consciousness every two (2) hours. 4. Monitor urine and serum osmolality. Rationale: Fluids are restricted to 500 to 600 mL per 24 hours. Orientation to person, place, and time should be assessed every two (2) hours or more often. Urine and serum osmolality are monitored to determine fluid volume status.

The nurse is admitting a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which clinical manifestations should be reported to the healthcare provider? 1. Serum sodium of 112 mEq/L and a headache. 2. Serum potassium of 5.0 mEq/L and a heightened awareness. 3. Serum calcium of 10 mg/dL and tented tissue turgor. 4. Serum magnesium of 1.2 mg/dL and large urinary output.

1. Serum sodium of 112 mEq/L and a headache. Rationale: A serum sodium level of 112 mEq/L is dangerously low, and the client is at risk for seizures. A headache is a symptom of a low-sodium level.

Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus? 1. Serum sodium. 2. Serum calcium 3. Urine glucose. 4. Urine white blood cells.

1. Serum sodium. Rationale: The client will have an elevated sodium level as a result of low circulating blood volume. The fluid is being lost through the urine. Diabetes means "to pass through" in Greek, indicating polyuria, a symptom shared with diabetes mellitus. Diabetes insipidus is a totally separate disease process.

The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? 1. Start an IV with an 18-gauge needle and infuse NS rapidly. 2. Have the client wait in the waiting room until a bed is available. 3. Obtain a permit for the client to receive a blood transfusion. 4. Collect urinalysis and blood samples for a CBC and calcium level.

1. Start an IV with an 18-gauge needle and infuse NS rapidly. Rationale: The client was exposed to wind and sun at the lake during the hours prior to being admitted to the emergency department. This predisposes the client to dehydration and an addisonian crisis. Rapid IV fluid replacement is necessary.

When assessing a client with full thickness burns, the nurse expects: 1. small, fluid filled blisters covering the area that has been burned. 2. decreased heart rate and increased blood pressure. 3. hyperactive bowel sounds with decreased digestion. 4. dry, leathery, waxy-white tissue.

4. dry, leathery, waxy-white tissue. Rationale: Full thickness burns destroy the first two layers of the skin, the epidermis and dermis, They appear very dry, leathery, and may appear white, red, or dark brown. There are no blisters associated with full thickness burns.

The healthcare provider has ordered 40g/24 hr of intranasal vasopressin for a client diagnosed with diabetes insipidus. Each metered spray delivers 10g. The client takes the medication every 12 hours. How many sprays are delivered at each dosing time? ______

2 sprays Rationale: 40 g of medication every 24 hours is to be given in doses administered every 12 hours. First, determine number of doses needed: 24 ÷ 12 = 2 doses Then, determine the amount of medication to be given in each of those two (2) doses: 40 ÷ 2 = 20 g of medication per dose Finally, determine how many sprays are needed to deliver the 20 mg when each spray delivers 10 g: 20 ÷ 10 = 2 sprays

The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention? 1. "I will keep a list of my medications in my wallet and wear a Medic Alert bracelet." 2. "I should take my medication in the morning and leave it refrigerated at home." 3. "I should weigh myself every morning and record any weight gain." 4. "If I develop a tightness in my chest, I will call my healthcare provider."

2. "I should take my medication in the morning and leave it refrigerated at home." Rationale: Medication for DI is usually taken every eight (8) to 12 hours, depending on the client. The client should keep the medication close at hand.

The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement? 1. Assess for dehydration and monitor blood glucose levels. 2. Assess for nausea and vomiting and weigh daily. 3. Monitor potassium levels and encourage fluid intake. 4. Administer vasopressin IV and conduct a fluid deprivation test.

2. Assess for nausea and vomiting and weigh daily. Rationale: 2. Early signs and symptoms are nausea and vomiting. The client has the syndrome of inappropriate secretion of antidiuretic (against allowing the body to urinate) hormone. In other words, the client is producing a hormone that will not allow the client to urinate.

The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before pain becomes severe. 2. Clean the client's wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers.

2. Clean the client's wounds, body, and hair daily. Rationale: Daily cleaning reduces bacterial colonization.

The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.

2. Deep partial thickness. Rationale: Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema.

The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? 1. "The doctor will graft skin from your back to your leg." 2. "The skin from a donor will be used to cover your burn." 3. "The graft will come from an animal, probably a pig." 4. "I think you should ask your doctor about the graft."

3. "The graft will come from an animal, probably a pig." Rationale: A xenograft or heterograft consists of skin taken from animals, usually porcine.

The unlicensed assistive personnel (UAP) complains to the nurse she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first? 1. Tell the UAP to fill the pitcher with ice cold water. 2. Instruct the UAP to start measuring the client's I&O. 3. Assess the client for polyuria and polydipsia. 4. Check the client's BUN and creatinine levels.

3. Assess the client for polyuria and polydipsia. Rationale: The first action should be to determine if the client is experiencing polyuria and polydipsia as a result of developing diabetes insipidus, a complication of the head trauma.

The nurse is caring for a client with deep partial thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the healthcare provider? 1. The client is complaining of severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4 o F, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in two (2) hours.

4. The client's urinary output is 50 mL in two (2) hours. Rationale: Fluid and electrolyte balance is the priority for a client with a severe burn. Fluid resuscitation must be maintained to keep a urine output of 30 mL/hr. Therefore, a 25-mL/hr output would warrant immediate intervention.

The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed. 2. Teach the client regarding sexual functioning and androgen replacement therapy. 3. Explain the signs and symptoms of infection and when to call the health-care provider. 4. Demonstrate turn, cough, and deep-breathing exercises the client should perform every two (2) hours.

3. Explain the signs and symptoms of infection and when to call the health-care provider. Rationale: Notifying the HCP of signs/symptoms of infection develop is an instruction given to all surgical clients on discharge.

The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which intervention should be implemented? 1. Administer sliding-scale insulin as ordered. 2. Restrict caffeinated beverages. 3. Check urine ketones if blood glucose is >250. 4. Assess tissue turgor every four (4) hours.

4. Assess tissue turgor every four (4) hours. Rationale: The client is excreting large amounts of dilute urine. If the client is unable to drink enough fluids, the client will quickly become dehydrated, so tissue turgor should be assessed frequently.

The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Ensure adequate peripheral circulation to both feet.

4. Ensure adequate peripheral circulation to both feet. Rationale: The client's legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes.

The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority? 1. Altered body image. 2. Activity intolerance. 3. Impaired coping. 4. Fluid volume deficit.

4. Fluid volume deficit. Rationale: Fluid volume deficit (dehydration) can lead to circulatory impairment and hyperkalemia.

The client diagnosed with Cushing's disease has developed 1++ peripheral edema. The client has received intravenous fluids at 100 mL/hr via IV pump for the past 79 hours. The client received intravenous piggyback (IVPB) medication in 50 mL of fluid every six (6) hours for 15 doses. How many mL of fluid did the client receive? ________

8,650 ml

During the first 24 hours after the female client sustained a 40% total body surface area (TBSA) burn, which lab value result is expected? Select all that apply. a. potassium of 4.2 mg/dL b. sodium of 139 mg/dL c. white blood cell of 8000 per mm3 d. hemoglobin of 18 g/dL e. hematocrit of 54%

d. hemoglobin of 18 g/dL e. hematocrit of 54% Rationale: Changes in laboratory test values are found in different phases of recovery after a burn is sustained. The resuscitation/emergent phase is the first phase of a burn injury. This occurs at the onset of the injury and continues through the first 48 hours after. During this phase the lab value changes will be related to the fluid shift and direct tissue damage. The potassium level (3.5-5.0 mEq/L) will be increased as a result of the disruption of the sodium-potassium pump, tissue destruction, and red blood cell hemolysis. Sodium (136-145 mEq/L) is trapped in edema fluid and lost through plasma leakage causing a decreased level. The hemoglobin (F 12-16 g/dL) and hematocrit (F 37-47%) will be elevated as a result of fluid volume loss that results in hemoconcentration.

The nurse is performing discharge teaching for a client diagnosed with Cushing's disease. Which statement by the client demonstrates an understanding of the instructions? 1. "I will be sure to notify my healthcare provider if I start to run a fever." 2. "Before I stop taking the prednisone, I will be taught how to taper it off." 3. "If I get weak and shaky, I need to eat some hard candy or drink some juice." 4. "It is fine if I continue to participate in weekend games of tackle football."

1. "I will be sure to notify my healthcare provider if I start to run a fever." Rationale: Cushing's syndrome/disease predisposes the client to develop infections as a result of the immunosuppressive nature of the disease.

The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention? 1. The client is alert to name but is unable to tell the nurse the location. 2. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL. 3. The client's vital signs are T 97.6ºF, P 88, R 20, and BP 130/80. 4. The client has a 3-cm amount of dark-red drainage on the turban dressing.

2. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL. Rationale: The output is more than double the intake in a short time. This client could be developing diabetes insipidus, a complication of trauma to the head.

The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis? 1. The client has an autoimmune problem causing the destruction of the adrenal cortex. 2. The client has been taking steroid medications for an extended period for another disease process. 3. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol. 4. The client has developed an adrenal gland problem for which the healthcare provider does not have an explanation.

2. The client has been taking steroid medications for an extended period for another disease process. Rationale: "Iatrogenic" means a problem has been caused by a medical treatment or procedure—in this case, treatment with steroids for another problem. Clients taking steroids over a period of time develop the clinical manifestations of Cushing's disease. Disease processes for which long-term steroids are prescribed include chronic obstructive pulmonary disease, cancer, and arthritis.

The male client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. Which action by the nurse is an example of the ethical principle of autonomy? 1. Discuss the information the client told the nurse with the healthcare provider and significant other. 2. Explain it is possible the client could have a seizure if he drank fluid beyond the restrictions. 3. Notify the healthcare provider of the client's wishes and give the client fluids as desired. 4. Allow the client an extra drink of water and explain the nurse could get into trouble if the client tells the healthcare provider.

3. Notify the healthcare provider of the client's wishes and give the client fluids as desired. Rationale: This is an example of autonomy (the client has the right to decide for himself).

The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse? 1. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. 2. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, Pao2 88, Paco2 44, and HCO 3 22. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.

3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28. Rationale: This client has a low blood pressure and tachycardia. This client may be experiencing an addisonian crisis, a potentially life-threatening condition. The most experienced nurse should care for this client.

The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday. 2. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours. 3. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. 4. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.

3. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. Rationale: Muscle twitching is a sign of early sodium imbalance. If an immediate intervention is not made, the client could begin to seize.

The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test? 1. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours. 2. The client will be administered an injection of antidiuretic hormone (ADH), and urine output will be measured for four (4) to six (6) hours. 3. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test. 4. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done.

3. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test. Rationale: The client is deprived of all fluids, and if the client has DI the urine production will not diminish. Vital signs and weights are taken every hour to determine circulatory status. If a marked decrease in weight or vital signs occurs, the test is immediately terminated.

The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, Pao2 98, Paco2 38, and HCO 3 20. 4. The client is able to perform active range-of-motion exercises.

3. The client's ABGs are pH 7.34, Pao2 98, Paco2 38, and HCO 3 20. Rationale: Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. These ABGs indicate metabolic acidosis and therefore require immediate intervention.

The injury that is least likely to result in a full-thickness burn is a. sunburn. b. scald injury. c. chemical burn. d. electrical injury.

a. sunburn. Rationale: Full-thickness burns may be caused by contact with flames, scalding liquids, chemicals, tar, or electrical current.

While providing care for a client that sustained a 4th degree burn, which clinical presentation is expected? Select all that apply. a. painful blisters surrounding the wound b. presence of blanching around wound c. presence of intense pain at site d. wound is blackened and depressed e. wound extends into the muscle and bone

d. wound is blackened and depressed e. wound extends into the muscle and bone Rationale: The fourth degree burn extends from the epidermis into the muscle/bone area. The wound is blackened and depressed, and sensation is completely absent.

The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.

1. Replace fluids and electrolytes. Rationale: After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes.

The nurse is planning the care of a client diagnosed with Addison's disease. Which intervention should be included? 1. Administer steroid medications. 2. Place the client on fluid restriction. 3. Provide frequent stimulation. 4. Consult physical therapy for gait training.

1. Administer steroid medications. Rationale: Clients diagnosed with Addison's disease have adrenal gland hypofunction. The hormones normally produced by the gland must be replaced. Steroids and androgens are produced by the adrenal gland.

The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit.

1. High risk for infection. Rationale: Although this is a potential problem, it is priority because the body's protective barrier, the skin, has been compromised and there is an impaired immune response.

Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change central lines once a week. 5. Administer antibiotics as prescribed.

1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 5. Administer antibiotics as prescribed. Rationale: Hand washing is the number-one intervention used to prevent infection, which is priority for the client with a burn. Aseptic techniques minimize risk of cross contamination and spread of bacteria. Aseptic techniques minimize risk of cross contamination and spread of bacteria. Antibiotics reduce bacteria.

The client is admitted to rule out Cushing's syndrome. Which laboratory tests should the nurse anticipate being ordered? 1. Plasma drug levels of quinidine, digoxin, and hydralazine. 2. Plasma levels of ACTH and cortisol. 3. A 24-hour urine for metanephrine and catecholamine. 4. Spot urine for creatinine and white blood cells (WBCs).

2. Plasma levels of ACTH and cortisol. Rationale: The adrenal gland secretes cortisol and the pituitary gland secretes adrenocorticotropic hormone (ACTH), a hormone used by the body to stimulate the production of cortisol.

The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess? 1. Moon face, buffalo hump, and hyperglycemia. 2. Hirsutism, fever, and irritability. 3. Bronze pigmentation, hypotension, and anorexia. 4. Tachycardia, bulging eyes, and goiter.

3. Bronze pigmentation, hypotension, and anorexia. Rationale: Bronze pigmentation of the skin, particularly of the knuckles and other areas of skin creases, occurs in Addison's disease. Hypotension and anorexia also occur with Addison's disease.

The nurse writes a problem of "altered body image" for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented? 1. Monitor blood glucose levels prior to meals and at bedtime. 2. Perform a head-to-toe assessment on the client every shift. 3. Use therapeutic communication to allow the client to discuss feelings. 4. Assess bowel sounds and temperature every four (4) hours.

3. Use therapeutic communication to allow the client to discuss feelings. Rationale: Allowing the client to ventilate feelings about the altered body image is the most appropriate intervention. The nurse cannot do anything to help the client's buffalo hump or moon face.

The nurse is teaching a patient with acromegaly from an unresectable benign pituitary tumor about octreotide therapy. The nurse should provide further teaching if the patient makes which statement? a. "The provider will infuse this medication through an IV." b. "I will inject the medication in the subcutaneous layer of the skin." c. "The medication should decrease the growth hormone production to normal." d. "I will have my growth hormone level measured every 2 weeks for several weeks."

a. "The provider will infuse this medication through an IV." Rationale: Drug therapy is an option for patients whose tumors are not surgically resectable. The primary drug used is octreotide, a somatostatin analog. It reduces growth hormone (GH) levels to normal in many patients. Octreotide is given by subcutaneous injection three times a week. GH levels are measured every 2 weeks to K guide drug dosing, and then every 6 months until the desired response is obtained.

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? a. Administer 100% humidified oxygen. b. Teach the patient deep breathing exercises. c. Encourage the patient to express his feelings. d. Assist the patient to a high Fowler's position.

a. Administer 100% humidified oxygen. Rationale: Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.

Which assessment finding would the nurse expect in a patient who has been taking oral prednisone several weeks and is experiencing sudden withdrawal? (Select all that apply.) a. BP 80/50 b. Heart rate 54 c. Glucose 63 mg/dL d. Sodium 148 mEq/L e. Potassium 6.3 mEq/L f. Temperature 101.1° F

a. BP 80/50 c. Glucose 63 mg/dL e. Potassium 6.3 mEq/L f. Temperature 101.1° F Rationale: Sudden cessation of corticosteroid therapy can precipitate life-threatening adrenal insufficiency. During acute adrenal insufficiency, the patient exhibits severe manifestations of glucocorticoid and mineralocorticoid deficiencies, including hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion.

Which is the most critical potential complication in a client diagnosed with acromegaly? a. Congestive heart failure. b. Elevated blood glucose. c. Enlarged extremities. d. Type I diabetes.

a. Congestive heart failure. Rationale: Acromegaly is caused by long term overproduction of growth hormone. Among some of the complications associated with exposure to excessive growth hormone is congestive heart failure due to hypertrophy of the heart muscle.

Which is/are the goal(s) of treatment for the client of hyperaldosteronism? Select all that apply. a. Decrease fluid volume b. Decrease sodium c. Decrease potassium d. Increase calcium e. Increase pH level

a. Decrease fluid volume b. Decrease sodium Rationale: The goals of treatment for hyperaldosteronism are to decrease fluid volume, decrease sodium levels, increase potassium levels, and decrease pH of the blood. These goals are due to the increased fluid volume, hypernatremia, hypokalemia, and increased pH (metabolic alkalosis).

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care? (Select all that apply.) a. Escharotomy b. Administration of diuretics c. IV and oral pain medications d. Daily cleansing and debridement e. Application of topical antimicrobial agent

a. Escharotomy c. IV and oral pain medications d. Daily cleansing and debridement e. Application of topical antimicrobial agent Rationale: An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instruction about desmopressin acetate would be most appropriate? a. Expect to have some nasal irritation while using this drug. b. Monitor for symptoms of hypernatremia as a drug side effect. c. Report any decrease in urinary output to the health care provider. d. Drink at least 3000 mL of water per day while taking this medication.

a. Expect to have some nasal irritation while using this drug. Rationale: Desmopressin acetate is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. Diuresis will be decreased and is expected. Inhaled desmopressin can cause nasal irritation, headache, nausea, and other signs of hyponatremia, not hypernatremia. Drinking too much water or other fluids increases the risk of hyponatremia. The patient should follow the provider's directions for limiting fluids and be taught to seek medical attention if they have severe nausea; vomiting; severe headache; muscle weakness, spasms, or cramps; sudden weight gain; unusual tiredness; mental/mood changes; seizures; and slow or shallow breathing.

The nurse is caring for a patient receiving high-dose oral corticosteroid therapy after a kidney transplant. Which side effect would the nurse monitor for as it presents the greatest risk? a. Infection b. Low blood pressure c. Increased urine output d. Decreased blood glucose

a. Infection Rationale: Side effects of corticosteroid therapy include increased susceptibility to infection, edema related to sodium and water retention (decreasing urine output), hypertension, and hyperglycemia.

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change? a. Morphine b. Sertraline c. Zolpidem d. Alprazolam

a. Morphine Rationale: Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and depression that patients may have.

The patient with systemic lupus erythematosus is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What interventions should be included in the plan of care? (Select all that apply.) a. Obtain daily weights. b. Limit fluids to 1000 mL/day. c. Administer diuretics as ordered. d. Monitor for signs of hypernatremia. e. Minimize turning and range of motion. f. Elevate the head of the bed at 10 degrees or less.

a. Obtain daily weights. b. Limit fluids to 1000 mL/day. c. Administer diuretics as ordered. f. Elevate the head of the bed at 10 degrees or less. The care for the patient with SIADH will include limiting fluids to 1000 mL/day or less to decrease weight, increase osmolality, and improve symptoms and keeping the head of the bed elevated at 10 degrees or less to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. Measure weights daily and maintain accurate intake and output. Monitor for signs of hyponatremia. Frequent turning, positioning, and range-of-motion exercises are important to maintain skin integrity and joint mobility.

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury? (Select all that apply.) a. Singed nasal hair b. Generalized pallor c. Painful swallowing d. Burns on the upper extremities e. History of being involved in a large fire

a. Singed nasal hair c. Painful swallowing e. History of being involved in a large fire Rationale: Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and dyspnea.

A patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor? a. Tachycardia b. Restlessness c. Hypokalemia d. Gastrointestinal (GI) distress

a. Tachycardia Rationale: Albuterol stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a noncardioselective agent, so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.

The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation? (Select all that apply.) a. Urine output is 46 mL/hr. b. Heart rate is 94 beats/min. c. Urine specific gravity is 1.040. d. Mean arterial pressure is 54 mm Hg. e. Systolic blood pressure is 88 mm Hg.

a. Urine output is 46 mL/hr. b. Heart rate is 94 beats/min. Rationale: Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, and heart rate less than 120 beats/min. Normal range for urine specific gravity is 1.003 to 1.030.

Pain management for the burn patient is most effective when (select all that apply) a. a pain rating tool is used to monitor the patient's level of pain. b. painful dressing changes are delayed until the patient's pain is completely relieved. c. the patient is informed about and has some control over the management of the pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury.

a. a pain rating tool is used to monitor the patient's level of pain. c. the patient is informed about and has some control over the management of the pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). Rationale: The use of a pain rating tool assists the nurse in the assessment, monitoring, and evaluation of the pain management plan. The more control the patient has in managing the pain, the more successful the chosen strategies are. A variety of medications offer pain relief for patients with burns, whose pain can be both continuous and treatment related over varying periods of time. It is not realistic to promise a patient that pain will be completely eliminated or managed (during any phase of burn care) with nonpharmacologic pain management. Such management is meant to be adjuvant and individualized

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a. applying pressure garments. b. repositioning the patient every 2 hours. c. performing active ROM at least every 4 hours. d. massaging the new tissue with water-based moisturizers.

a. applying pressure garments. Rationale: Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters. b. exposed fascia. c. exposed muscles. d. intact nerve endings. e. red, shiny, wet appearance.

a. blisters. d. intact nerve endings. e. red, shiny, wet appearance. Rationale: The appearance of partial-thickness (deep) burns may include fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema

To maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, high-carbohydrate diet. b. increase normal caloric intake by about four times. c. eat at least 1500 calories/day in small, frequent meals. d. eat a gluten-free diet for the chemical effect on nitrogen balance.

a. eat a high-protein, high-carbohydrate diet. Rationale: The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delays in healing.

After a hypophysectomy for acromegaly, immediate postoperative nursing care should focus on a. frequent monitoring of serum and urine osmolarity. b. parenteral administration of a GH-receptor antagonist. c. keeping the patient in a recumbent position at all times. d. patient teaching about the need for lifelong hormone therapy.

a. frequent monitoring of serum and urine osmolarity. Rationale: A possible postoperative complication after a hypophysectomy is transient diabetes insipidus (DI). It may occur because of the loss of antidiuretic hormone (ADH), which is stored in the posterior lobe of the pituitary gland, or because of cerebral edema related to manipulation of the pituitary gland during surgery. To assess for DI, urine output and serum and urine osmolarity should be monitored closely

To control the side effects of corticosteroid therapy, the nurse teaches the patient who is taking corticosteroids to a. increase calcium intake to 1500 mg/day. b. perform glucose monitoring for hypoglycemia. c. obtain immunizations due to high risk for infections. d. avoid abrupt position changes because of orthostatic hypotension.

a. increase calcium intake to 1500 mg/day. Rationale: Because patients often receive corticosteroid treatment for prolonged periods (more than 3 months), corticosteroid-induced osteoporosis is an important concern. Therapies to reduce bone resorption may include increased calcium intake, vitamin D supplementation, bisphosphonates (e.g., alendronate), and taking part in a low-impact exercise program.

A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? a. 18% b. 22.5% c. 27% d. 36%

b. 22.5% Rationale: Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover about 22.5% of the total body surface area.

When teaching the patient in the rehabilitation phase of a severe burn about performing range of motion (ROM), what explanations should the nurse give to the patient? (Select all that apply.) a. The exercises are the only way to prevent contractures. b. Active and passive ROM maintains function of body parts. c. ROM will reassure the patient that movement is still possible. d. Movement promotes mobilization of interstitial fluid back into the vascular bed. e. Active and passive ROM can only be done while the dressings are being changed.

b. Active and passive ROM maintains function of body parts. c. ROM will reassure the patient that movement is still possible. d. Movement promotes mobilization of interstitial fluid back into the vascular bed. Rationale: Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM and splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

Which priority assessment finding would the nurse immediately report on a 48-hour adrenalectomy client? a. Temperature reading of 99.5 F (37.5 C) and 99.6 F (37.6 C) b. Blood pressure readings of 92/60 and 88/58 mm Hg c. Surgical site with slight redness, edema, well-approximated d. PaCO2 44 mm Hg, HCO3 22 mEq/L, PaO2 80 mmHg, pH of 7.35

b. Blood pressure readings of 92/60 and 88/58 mm Hg Rationale: The priority assessment finding the nurse should report for a 48-hour postoperative adrenalectomy client is the blood pressure of 90/60 and 88/58 mm Hg which indicates hypotension. This is concerning especially after an adrenalectomy because there is not enough cortisol to maintain an adequate blood pressure so the client can go into adrenal or Addison's crisis.

Which prescription does the nurse question when caring for a client admitted with secondary hyperaldosteronism? Select all that apply. a. Place on a 24-hour a day telemetry monitor b. Furosemide 20 mg IV push every 12 hours c. IV fluids of 0.9% normal saline at 200 ml/hr d. Spironolactone 50 mg PO twice daily e. Monitor VS every 2 hours, report systolic BP >140

b. Furosemide 20 mg IV push every 12 hours c. IV fluids of 0.9% normal saline at 200 ml/hr Rationale: Hyperaldosteronism is a condition of the endocrine system where one or both adrenal glands produce too much aldosterone hormone. Secondary hyperaldosteronism causes increased aldosterone levels from adrenal production. Symptoms are very similiar to symptoms of primary hyperaldosteronism. Treatment includes the use of spironolactone, a potassium sparing diuretic, to decrease fluid without decreasing the potassium further, placing on a telemetry monitor, monitoring VS, especially blood pressures, monitoring electrolytes, potassium and sodium, and if there is a tumor, removal of the tumor.

A nurse caring for a client with hyperaldosteronism would report which concerning symptom to the health care provider? a, Weight loss of 2.2 lbs or 1 kg b. Headache with pain 6/10 c. Potassium level of 3.6 mEq/L d. Sodium level of 144 mEq/L

b. Headache with pain 6/10 Rationale: A headache is concerning when a client has hyperaldosteronism because it usually indicates an elevated blood pressure, which can rise to a dangerous level with this condition. Due to the elevated sodium, headache can also be a symptom that occurs just before confusion and seizures.

The patient in the emergency department after a car accident is wearing medical identification listing Addison's disease. What should the nurse expect to be included in the care of this patient? a. Low-sodium diet b. Increased glucocorticoid replacement c. Limiting IV fluid replacement therapy d. Withholding mineralocorticoid replacement

b. Increased glucocorticoid replacement Rationale: The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addison's may need large volumes of IV fluid replacement and a high-sodium diet. Withholding mineralocorticoid replacement cannot be done for patients with Addison's disease.

An older adult is moving into an independent living facility. What teaching will prevent this patient from being accidently burned in the new home? a. Encourage her to stop smoking. b. Install tap water anti-scald devices. c. Ensure all meals are cooked for her. d. Be sure she uses an open space heater.

b. Install tap water anti-scald devices. Rationale: Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.

The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient? a. Subcutaneous (SQ) tetanus toxoid b. Intravenous (IV) morphine sulfate c. Intramuscular (IM) hydromorphone d. Oral oxycodone and acetaminophen

b. Intravenous (IV) morphine sulfate Rationale: IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption that would occur with the IM route. The PO route is not used because GI function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.

The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? a. Begin IV fluid replacement. b. Monitor for signs of complications. c. Assess and manage pain and anxiety. d. Discuss possible reconstructive surgery.

b. Monitor for signs of complications. Rationale: Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? a. Blisters b. Reddening of the skin c. Destruction of all skin layers d. Damage to sebaceous glands

b. Reddening of the skin Rationale: The clinical appearance of superficial partial-thickness burns includes reddening of the skin, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? a. Skin is hard with a dry, waxy white appearance. b. Skin is shiny and red with clear, fluid-filled blisters. c. Skin is red and blanches when slight pressure is applied. d. Skin is leathery with visible muscles, tendons, and bones.

b. Skin is shiny and red with clear, fluid-filled blisters. Rationale: Deep partial-thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial-thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.

Important nursing intervention(s) when caring for a patient with Cushing syndrome include (select all that apply) a. restricting protein intake. b. monitoring blood glucose levels. c. observing for signs of hypotension. d. administering medication in equal doses. e. protecting patient from exposure to infection.

b. monitoring blood glucose levels. e. protecting patient from exposure to infection. Rationale: Hyperglycemia occurs with Cushing disease because of glucose intolerance associated with cortisol-induced insulin resistance and increased gluconeogenesis by the liver. High levels of corticosteroids increase risk of infection and delay wound healing.

A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the wound bed. b. observe the wound for signs of infection during dressing changes. c. apply cool compresses for pain relief in between dressing changes. d. wash the wound aggressively with soap and water three times a day.

b. observe the wound for signs of infection during dressing changes. Rationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis.

Which clinical manifestation assessed in a client admitted to the intensive care unit confirms a diagnosis of Cushing's syndrome? Select all that apply. a. hypotension b. purple striae c. hirsutism d. moon face e. truncal obesity

b. purple striae c. hirsutism d. moon face e. truncal obesity Rationale: In Cushing's syndrome all body systems are affected by hypercortisolism. Skin manifestations include: thinning skin, rosey cheeks, increased pigmentation, hirsutism, and purple striae on the face and abdomen.

While providing care for the client diagnosed with diabetes insipidus, which presentation is expected? Select all that apply. a. apical heart rate of 60 beats/minute b. blood pressure of 178/100 c. 24-hour urine output of 10 liters d. specific gravity of 1.005 g/mL e. Sodium level greater than 145 mEq/L

c. 24-hour urine output of 10 liters d. specific gravity of 1.005 g/mL e. Sodium level greater than 145 mEq/L Rationale: The first step of diagnosis is to measure a 24-hour fluid intake and output. With diabetes insipidus (DI) a urine output of more than 4 liters in 24 hours is an indicator of DI. The urine excreted in a 24-hour time period may vary from 4 to 30L/day. The urine is dilute with a specific gravity less than 1.005. A lack of body fluids causes an increase in electrolyte concentrations, specifically sodium. The problem of dehydration and hypovolemia will present with hypotension and tachycardia.

Which patient should the nurse prepare to transfer to a regional burn center? a. A 25-yr-old pregnant patient with a carboxyhemoglobin level of 1.5% b. A 39-yr-old patient with a partial-thickness burn to the right upper arm c. A 53-yr-old patient with a chemical burn to the anterior chest and neck d. A 42-yr-old patient who is scheduled for skin grafting of a burn wound

c. A 53-yr-old patient with a chemical burn to the anterior chest and neck Rationale: The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to manage this type of trauma. Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.

What should be included in the interprofessional plan of care for a patient with Cushing disease? a. Lab monitoring for hyperkalemia b. Vital sign monitoring for hypotension c. Counseling related to body image changes d. Diet consultation to determine low protein choices

c. Counseling related to body image changes Rationale: Elevated corticosteroid levels can cause body changes, including truncal obesity, moon face, and hirsutism in women and gynecomastia in men. Counseling and support should be offered because of the changes in body image. Hypokalemia and hypertension are consistent with Cushing disease. Sodium restriction and potassium supplementation are indicated. High-protein choices are necessary to counteract catabolic processes and assist with wound healing.

Which prevention strategy would the nurse include when teaching about home fire safety? a. Set hot water temperature at 140°F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Do not allow older adults to cook unattended.

c. Encourage regular home fire exit drills. Rationale: A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Hot water heaters set at 120° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used. Supervision of older adults who are cooking is necessary if cognitive impairment is present.

What is the underlying pathophysiology for edema in clients with Cushing syndrome? a. Excess potassium b. Decreased sodium c. Excess aldosterone d. Decreased angiotensin II

c. Excess aldosterone Rationale: Cushing syndrome is a disorder of the adrenal cortex which results in overproduction of aldosterone, cortisol, and androgens. Aldosterone causes the kidneys to retain sodium and fluid so its presence in excess is responsible for peripheral edema in clients with Cushing syndrome.

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. Mannitol 75 gram IV b. Urine for myoglobulin c. Lactated Ringer's solution at 25 mL/hr d. Sodium bicarbonate 24 mEq every 4 hours

c. Lactated Ringer's solution at 25 mL/hr Rationale: Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's solution at 2 to 4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.

The nurse is caring for a client with syndrome of inappropriate diuretic hormone (SIADH). Which finding does the nurse expect when assessing this client? a. BP 78/42 b. Decreased LOC c. Lower extremity edema d. Weight loss

c. Lower extremity edema Rationale: SIADH is an endocrine disorder in which antidiuretic hormone is secreted in excess amounts causing the kidneys to retain fluid. This leads to signs and symptoms of fluid volume overload. Clients with SIADH will experience edema, hypertension, bounding pulses, weight gain, and other signs of excess fluid volume.

A patient with type 2 diabetes is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this patient? a. Replace the blood lost. b. Maintain a neutral pH. c. Maintain fluid balance. d. Replace serum potassium.

c. Maintain fluid balance. Rationale: This patient most likely has hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? a. The total 24-hour fluid requirement should be administered in the first 8 hours. b. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. c. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. d. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.

c. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. Rationale: Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.

The nurse has received a report from the lab about a client with hyperaldosteronism and the client's critical potassium of 2.9 mEq/L and sodium level of 146 mEq/L. The charge nurse is calling the healthcare provider. What is the nurse's first priority? a. Recheck the potassium and sodium level b. Place the client in Trendelenburg position c. Prepare to place the client on a telemetry monitor d. Encourage the client to drink 2L of water

c. Prepare to place the client on a telemetry monitor Rationale: Hyperaldosteronism can cause hypokalemia so the blood levels should be monitored. A level of 2.9 mEq/L is a very low potassium level and places the client at risk for severe cardiac arrhythmias and risk of death. The client should be placed on a telemetry monitor.

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? a. Sit or lie in the position of comfort. b. Wear a pressure garment for 8 hours each day. c. Refer the patient to a counselor for psychosocial support. d. Use the sun to increase the skin color on the healed areas.

c. Refer the patient to a counselor for psychosocial support. Rationale: In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way the patient looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours/day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls. b. movement of potassium into the vascular space. c. movement of sodium and water into the interstitial space. d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

c. movement of sodium and water into the interstitial space. Rationale: During the emergency phase, sodium and water rapidly shift to the interstitial spaces and stay there until edema formation ceases.

An important preoperative nursing intervention before an adrenalectomy for hyperaldosteronism is to a. monitor blood glucose levels. b. restrict fluid and sodium intake. c. administer potassium-sparing diuretics. d. advise the patient to make postural changes slowly.

c. administer potassium-sparing diuretics. Rationale: Before surgery, patients should be treated with potassium-sparing diuretics (spironolactone, eplerenone) to normalize serum potassium levels. Spironolactone and eplerenone block the binding of aldosterone to the mineralocorticoid receptor in the terminal distal tubules and collecting ducts of the kidney. This increases sodium excretion, water excretion, and potassium retention. Oral potassium supplements may be needed.

While providing care for a client diagnosed with Syndrome of Inappropriate Antidiuretic Hormone (SIADH), which clinical manifestation will be anticipated? Select all that apply. a. increased hunger b. overly excited c. confusion d. severe headache e. elevated blood pressure

c. confusion d. severe headache e. elevated blood pressure Rationale: Clinical manifestations of SIADH are related to hyponatremia and decreased extracellular fluid osmolarity, both of which result in cerebral edema. As the sodium level decreases, symptoms will present. Initially, the presentation involves nausea and malaise. As hyponatremia worsens, the presentation includes headache, lethargy, and leads to seizures if not corrected.

Which clinical manifestation will occur in the client diagnosed with diabetes insipidus? Select all that apply. a. decreased urine output b. increased blood pressure c. dilute, odorless urine d. dry mucous membranes e. increased thirst

c. dilute, odorless urine d. dry mucous membranes e. increased thirst Rationale: Diabetes insipidus occurs when the kidneys cannot concentrate the urine normally, and a large amount of dilute urine is excreted. Most manifestations of DI are related to the dehydration that occurs with the excretion of large volumes of diluted urine.

Which clinical manifestation is expected in the 8 year old client diagnosed with excessive growth hormone secretion? Select all that apply. a. enlarged body organs b. enlarged protruding eyes c. large hands and feet d. thick deep creased skin e. extreme height for age

c. large hands and feet d. thick deep creased skin e. extreme height for age Rationale: The effects of excessive growth hormone can present as two different disorders: gigantism and acromegaly. Gigantism is the result of excessive growth hormone secretion during childhood. Acromegaly occurs in the adult experiencing excessive growth hormone secretion. The presentation of excessive growth hormone includes: overgrowth of the long bones, thickened deep creased skin,and large hands and feet. The cause of increased growth hormone secretion is related to a benign tumor of the anterior pituitary.

When working with a client diagnosed with Cushing's syndrome which is considered a cause? Select all that apply. a. damage to adrenal gland b. autoimmune response c. long-term steroid therapy d. pituitary adenoma e. small cell carcinoma

c. long-term steroid therapy d. pituitary adenoma e. small cell carcinoma Rationale: Cushing's syndrome/disease occurs with excessive secretion of corticosteroids. The problem is seen as excessive secretion of cortisol from the adrenal cortex. Exogenous administration (Cushing's syndrome) occurs from long term steroid therapy as in the treatment for asthma, chronic fibrosis, and autoimmune disorders.

A patient with a head injury develops SIADH. Manifestations the nurse would expect to find include a. hypernatremia and edema. b. muscle spasticity and hypertension. c. low urine output and hyponatremia. d. weight gain and decreased glomerular filtration rate.

c. low urine output and hyponatremia. Rationale: Excess ADH increases the permeability of the renal distal tubule and collecting ducts, which leads to the reabsorption of water into the circulation. Thus, extracellular fluid volume expands, plasma osmolality declines, the glomerular filtration rate increases, and sodium levels decline (i.e., dilutional hyponatremia). Hyponatremia causes muscle cramping, pain, and weakness. At first, the patient has thirst, dyspnea on exertion, and fatigue. Patients with the syndrome of inappropriate antidiuretic hormone secretion (SIADH) have low urinary output and increased body weight. As the serum sodium level falls (usually to less than 120 mEq/L), manifestations become more severe and include headache, vomiting, abdominal cramps, muscle twitching, and seizures. As plasma osmolality and serum sodium levels continue to decline, cerebral edema may occur, leading to lethargy, anorexia, confusion, seizures, and coma.

A patient is recovering from second- and third-degree burns over 30% of his body, and the burn care team is planning for discharge. The first action the nurse should take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. teach the patient and the caregiver proper wound care to be performed at home. c. review the patient's current health care status and readiness for discharge to home. d. give the patient written information and websites for information for burn survivors.

c. review the patient's current health care status and readiness for discharge to home. Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The burn care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated soon. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge.

While providing care for a client diagnosed with Addison's disease, which clinical manifestation is expected? Select all that apply. a. hypertension b. pale, thin skin c. salt craving d. decreased weight e. cold intolerance

c. salt craving d. decreased weight e. cold intolerance Rationale: Adrenal insufficiency, also known as Addison's disease, is related to an insufficiency of adrenocortical steroids. Clinical manifestations of Addison's disease depend on the degree of hormone deficiency. Gastrointestinal manifestations include: weight loss, salt craving, and anorexia.

What is the total body surface area (TBSA) of injury for the client that sustained a burn, anterior arms and head/neck, as well as the chest and abdomen? a. 27 b. 45 c. 18 d. 32

d. 32 Rationale: For the client that sustains a burn, it is important to assess the skin to determine the size and depth of burn injury. This is estimated in comparison with the total body surface area (TBSA). For this client each anterior arm is 4.5% (9% total), the anterior head/neck is 4.5%, the chest is 9%, and the abdomen is 9%. The total is rounded to the next whole number.

What is the total body surface area and degree of burn for the client that sustained burns to the anterior right leg that appears reddened and blanches easily? a. 10%; 2nd degree b. 4%; 1st degree c. 5%; 2nd degree d. 9%; 1st degree

d. 9%; 1st degree Rationale: The client's burn involving the anterior right leg and appearing as reddened with easy blanching reflects a specific TBSA and degree of burn. The total body surface area is 9% and the degree of burn is 1st degree. The legs are 18% ((9% anterior, 9% posterior) each. The first degree burn involves damage to the epidermis. The skin will appear red and dry, with blanching assessed.

A patient with a severe pounding headache has been diagnosed with hypertension. However, the hypertension is not responding to traditional treatment. What should the nurse expect as the next step in determining a diagnosis for this patient? a. Administration of β-blocker medications b. Abdominal palpation to search for a tumor c. Administration of potassium-sparing diuretics d. A 24-hour urine collection for fractionated metanephrines

d. A 24-hour urine collection for fractionated metanephrines Rationale: Pheochromocytoma should be suspected when hypertension does not respond to traditional treatment. The 24-hour urine collection for fractionated metanephrines is simple and reliable with elevated values in 95% of people with pheochromocytoma. In a patient with pheochromocytoma, an α-adrenergic receptor blocker is used preoperatively to reduce blood pressure. Abdominal palpation is avoided to avoid a sudden release of catecholamines and severe hypertension. Potassium-sparing diuretics are not needed. Most likely they would be used for hyperaldosteronism, which is another cause of hypertension.

A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Which action is the most appropriate for the nurse to take next? a. Encourage the patient to cough and auscultate the lungs again. b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. c. Document the findings and continue to monitor the patient's breathing. d. Anticipate the need for endotracheal intubation and notify the provider.

d. Anticipate the need for endotracheal intubation and notify the provider. Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide (CO). The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.

The patient with an adrenal hyperplasia is returning from surgery after an adrenalectomy. The nurse should monitor the patient for what immediate postoperative complication? a. Vomiting b. Infection c. Thromboembolism d. Rapid blood pressure changes

d. Rapid blood pressure changes Rationale: The risk of hemorrhage is increased with surgery on the adrenal glands as well as large amounts of hormones being released in the circulation, which may produce hypertension and cause fluid and electrolyte imbalances to occur for the first 24 to 48 hours after surgery. Vomiting, infection, and thromboembolism may occur postoperatively with any surgery.

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? a. Serum sodium and potassium increase. b. Serum sodium and potassium decrease. c. Edema and arterial blood gases improve. d. Diuresis occurs and hematocrit decreases.

d. Diuresis occurs and hematocrit decreases. Rationale: Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? a. Full liquids only b. Whatever the patient requests c. High-protein and low-sodium foods d. High-calorie and high-protein foods

d. High-calorie and high-protein foods Rationale: A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? a. Severe pain, blisters, and blanching with pressure b. Pain, minimal edema, and blanching with pressure c. Redness, evidence of inhalation injury, and charred skin d. No pain, waxy white skin, and no blanching with pressure

d. No pain, waxy white skin, and no blanching with pressure Rationale: With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.

When completing an assessment on a client, the nurse would consider which abnormal finding related to the endocrine system? a. A blood pressure of 112/80. b. A weight gain of 10 pounds over a 6 month period. c. Two soft, formed bowel movements daily. d. Poor growth and development.

d. Poor growth and development. Rationale: Poor growth and development could indicate a number of endocrine disorders related to the thyroid or pituitary glands. A deficiency in growth hormone could be the underlying etiology for this abnormal finding as well. Hormones produced by the anterior pituitary gland as well as the thyroid gland play a role in growth and development in children. If one of these glands is not functioning properly or producing enough hormone, a child may not meet specified growth and development goals. Delayed growth and development should be investigated further for the underlying etiology.

The most critical potential complications of long-term growth hormone excess include: a. weight loss and mental dullness. b. poor growth and development. c. development of a pituitary adenoma. d. hypertension and diabetes mellitus.

d. hypertension and diabetes mellitus. Rationale: Acromegaly is the term used to describe the excess secretion of growth hormone after closure of the epiphyseal plates. It is usually caused by a growth hormone secreting tumor around the pituitary. Features include enlargement of the hands and feet and abnormal facial characteristics. However, the most critical and serious potential complications of excess growth hormone include insulin resistance causing diabetes and cardiac complications such as hypertension.

Which lab value result supports the diagnosis of Syndrome of Inappropriate Antidiuretic Hormone (SIADH)? Select all that apply. a. blood glucose level of 100 mg/dL b. creatinine level of 2.0 mg/dL c. potassium level of 2.8 mEq/L d. specific gravity of 1.036 g/mL e. sodium level of 128 mEq/L

d. specific gravity of 1.036 g/mL e. sodium level of 128 mEq/L Rationale: There are specific lab value results that support the diagnosis of SIADH. These lab value results include a specific gravity of 1.035 g/mL and sodium level of 128 mEq/L. In Syndrome of Inappropriate antidiuretic hormone (SIADH) there is a dysfunction in the ability of the antidiuretic hormone from functioning properly. Even when the plasma is hypo-osmolar, the antidiuretic hormone continues to be released. Water is retained, which results in dilutional hyponatremia and expansion of the extracellular fluid volume.