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NUR 265 Exam 3
Terms in this set (87)
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action?
Document the findings
Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this
Three days after a burn injury, the client develops a temperature of 100° F, white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which
wound to the LPN. Which instruction is most important for the RN to provide the LPN?
Wash hands upon entering the clients room
What intervention will the nurse implement to reduce a client's pain after a burn injury?
Administer 4mg Morphine IV
What statement indicates the client needs further education regarding the skin grafting (allografting)?
"Because the graft is my own skin, there is no chance it won't 'take.'
When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination?
Changing gloves between wound care on different parts of the client's body
Which assessment finding assists the nurse in confirming inhalation injury?
Which finding indicates that fluid resuscitation has been successful for a client with a burn injury?
Urine output = 50ml/HR
Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance?
Performing his own morning care.
Indicators that the client with a burn injury has a positive perception of his appearance includes the willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the
Which finding indicates to the nurse that the client understands the psychosocial impact of his severe burn injury?
It is normal to feel depressed.
Which finding is characteristic during the emergent period after a deep full thickness burn injury?
Urine output of 10ml/hr
During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreaseD. Foul-smelling discharge does not occur during the emergent phase and blood pressure is usually low. Pain does not occur with deep full-thickness burns.
Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain?
Decreased tissue perfusion
During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury and a disrupted breathing pattern. Disturbed body image and disuse syndrome can develop. However, these are not priority diagnoses at this time.
Which laboratory result, obtained on a client 24 hours post-burn injury, will the nurse report to the physician immediately?
Serum potassium,7.5 mmol/L (mEq/L)
Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is recovering from a thermal burn injury?
Allowing the client to eat whenever he or she wants
Clients should request food whenever they think that they can eat, not just according to the hospital's standard meal schedule. The nurse needs to work with a nutritionist to provide a high-calorie, high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications.
hich statement best exemplifies the client's understanding of rehabilitation after a full-thickness burn injury?
"My goal is to achieve the highest level of functioning that I can"
Which statement indicates that a client with facial burns understands the need to wear a facial pressure garment?
"My facial scars will be less with the use of this facial mask"
he client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action
Loosen the dressing
During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?
Increased serum creatinine levels.
The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?
MI 1 year ago
A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge?
Learning to perform dressing changes
A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first?
Begin IV fluids
A client who was burned has crackles and a respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first?
Place the client in an upright position.
Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in the upright position can relieve the lung congestion immediately before other measures can be carried out. Digoxin may be given later to increase cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid of fluid. Monitoring urine output is important. However it is not an immediate intervention.
How will the nurse position a client with a burn wound to the posterior neck to prevent contractures?
Have the client turn head from side to side
On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action?
Preparing for intubation
Ten hours after the client with 50% burns is admitted, her blood glucose level is 140 mg/dL. What is the nurse's best action?
Documents the findings
The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury?
The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a "small amount of pain." How will the nurse categorize this injury?
The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client?
HR and rhythm
The client has severe burns around the right hip. Which position is most important to use to maintain maximum function of this joint?
Hip at zero flexion with leg flat
The client who is burned is drooling and having difficulty swallowing. Which action will the nurse take first
Auscultates breath sounds over the trachea and mainstem Bronchi
The client with a full-thickness burn is being discharged to home after a month in the hospital. His wounds are minimally opened and he will be receiving home care. Which nursing diagnosis has the highest priority?
The client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse's best response?
This will help prevent stomach ulcers
The client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide?
You will not look exactly the same
The client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which is the nurse's best action?
Preparing to do a work up for sepsis
The family of a client who has been burned asks at what point the client will no longer be at greater risk for infection. What is the nurse's best response?
When the burn wounds are closed
The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first?
Removes loose non-viable tissue
The nurse uses topical gentamicin sulfate (Garamycin) on a client's burn injury. Which laboratory value will the nurse monitor?
the client diagnosed with a mild concussion is being discharged from the emergency department. which discharge instruction should the nurse teach the clients significant other? 1. awake in the client every 2 hours. 2. monitor for increased intracranial pressure. 3. observe frequently for hypervigilance. 4. offer the client food every 3 to 4 hours.
answer 1. Awakening the client every 2 hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety, all signs a post concussion syndrome ,which would warrant a return to the emergency department.
he resident in a long term care facility Fell during the previous shift and has a laceration in the occiptal area that has been closed with steri strips. Which signs or symptoms would warrant transferring the resident to the emergency department?1. A 4 centimeters area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that's resolved with medication.
2. These signs and symptoms indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.
the nurse is caring for the following clients. Which client what the nurse assess first after receiving the shift report? 1. The 22 year old male client diagnosed with a concussion who is complaining someone is waking him up every 2 hours. 2. The 36 year old female client admitted with complaints of left sided weakness who is scheduled for an MRI scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. 4. The 62-year-old client diagnosed with CVA who has expressive aphasia
3. The Glasgow Coma Scale is used to determine a client's response to stimuli such asEye opening response, best verbal response, and best motor response secondary to a neurological problem scores range from 3 which is a deep coma to 15 which is intact neurological function. A client with a score of 6 should be assessed First
the client has sustained a severe closed head injury and the neurosurgeon is determining if the client is brain dead. Which data support That the client is brain dead?1. The clients head is turned to the right, the eyes turn to the righT. 2. the EEG has identifiable waveforms. 3. There is no Eye activity when the cold caloric test is performed. 4 the client assumes decorticate posturing when painful stimuli are applied.
3. The cold caloric test, also called the ocular vestibular test, is used to determine if the brain is intact or dead. No Eye activity indicates brain death. If the client eyes moved, that would indicate that the brainstem is intact
the client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess nurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.
4. The most important nursing goal in the management of a client with a head injury is to establish and maintain adequate airway
the client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order with the nurse question? 1. A subcutaneous anti coagulant. 2. An intravenous osmotic diuretics. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.
2. An Osmotic diuretic is ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit
the clients diagnosed with a gunshot wound to the head assumes decorticate pOsturing when the nurse applies painful stimuli. Which assessment data obtained 3 hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 millimeters in size and nonreactive to painful stimuli.
1. purposeless movement indicates that the clients cerebral edema is decreasing. The best motor responses purposeful movement, but purpose less movement indicates an improvement over the Decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity
the nurse is caring for a client diagnosed with epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93 percent. 4. Perform deep Nasal suction every 2 hours. 5. Administer mild sedative.
correct answers 2, 3,5. Stool softeners are initiated to prevent the Bell sell the maneuver which increaseS ICP. oxygen saturation higher the 93 percent ensures oxygenation of the brain tissues. decreasing oxygen levels increase cerebral edema.mild sedative will reduce the clans agitation. Strong narcotics would not be administered because they decrease the clients loc
the client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2x2 Gauze under the nose to collect drainage.
3. The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid and the HCP should be notified immediately
the nurse is enjoying a day out at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the clients loc. 2. Organize onlookers to remove the client from the lake. 3. Perform a head to toe assessment to determine injuries. 4. Stabilize the clients cervical spine.
4. The nurse should always assume that the client with traumatic head injury may have sustained spinal cord injury. Moving the client could further injure the spinal cord and cause paralysis.Therefore the nurse should stabilize the cervical spinal cordas best as possible prior to removing the client from the water.
the client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as high risk for immobility complications. Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Performed active range of motion exercises every 4 hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.
1. The head of the clients bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility
the 29-year-old client that was employed as a forklift operator sustains a traumatic brain injury secondary to a motor vehicle accident. The client is being discharged from the rehabilitation unit after 3 months and has cognitive deficits. Which goal would be more realistic for this client? 1. The client will return to work within 6 months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain power and bladder control.
2 . Cognitive pertains to mental processes of comprehension, judgment, memory, and reasoning
The nurse has given the male client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will:
Exposure to cold and drafts
A female client with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness?
C. Providing information, giving positive feedback, and encouraging relaxation
A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client's behavior
B. Affect is flat, with periods of emotional lability
The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relates to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.
The nurse assesses clear fluid coming from the nose and ears of a client admitted to the Emergency Department after a fall. The fluid is found to be cerebral spinal fluid. Based on this information, the nurse plans care for a client with which type of fracture?
A client was admitted to the ICU after sustaining a closed head injury. Several hours later, the nurse assesses that the client is more lethargic and confused, is mumbling her speech, and is very difficult to arouse. The nurse takes action on this assessment for which reason?
The clients brain injury might be worsening
A client who sustained a closed head injury has elevation of ICP. Currently the client is putting out nearly a liter of pale urine each hour. The client is diagnosed with diabetes insipidus (DI). The nurse prepares for interventions based on which pathophysiology?
The client is not producing enough ADH
A client has been in the ICU for 6 weeks for treatment of a traumatic head injury. Brain death has just been declared. Which assessment findings would the nurse anticipate? Select all that apply.
Loss of brain stem reflexes
Presence of coma
A physician order for additional mannitol (Osmitrol) has been written for a client with increased ICP. Which assessment finding would cause the nurse to question this order?
The client is hypovolemic
A client sustained a closed head injury in a fall from a tree that happened 2 hours ago. There is MRI evidence of a contusion. The client has just begun to regain consciousness and has a current Glasgow Coma Scale (GCS) score of 11. The nurse should plan care for a client with which level of injury from this contusion
A client is made hypothermic as treatment for a severe traumatic brain injury. The nurse should monitor for which complications of this therapy? Select all that apply
Which nursing action would help to optimize the client's cerebral perfusion pressure (CPP)?
Log roll the patient
Treat fever with antipyretic a as ordered
A client presents to the Emergency Department with a head injury received in a fall at home. On admission, the client's Glasgow Coma Scale (GCS) score is 12. Within 20 minutes of arrival, the GCS is 8. What should the nurse do?
Prepare the client for intubation
A client who sustained a head injury has been diagnosed with SIADH. Which nursing action is necessary?
Maintain fluid restriction
A client has increased ICP. The nurse intervenes to keep the client's neck in a neutral position for which reason?
To allow easier drainage of CSF
A client brought to the Emergency Department following a fall at home is both hypoxemic and hypercapnic. The nurse intervenes rapidly to prevent which additional complication?
A nurse asks for help with a client who is exhibiting decorticate posturing. The nurse who assists would expect which client movement?
Flexion of the arms to the chest.
A client with head trauma and resultant increased ICP and coma is being evaluated in the ICU. The nurse would question an order to prepare the client for which diagnostic examination?
A nurse wishes to use central stimulation to assess the response of a client who is unconscious. The nurse would avoid using supraorbital pressure in which clients? Select all that apply
Hx of glaucoma
Recent frontal crainotomy
A client suffered a head injury in an explosion. The client has awakened from a 2-day coma. When asked what happened, the client haltingly says, "Cup two duck." The nurse documents this as which kind of aphasia?
A client has damage to the right side of the brain. On which side would the nurse anticipate pupillary changes?
The medical team is preparing to conduct oculovestibular testing of a client in a coma. What materials should the nurse collect for this testing?
Last week a client sustained a gunshot wound that caused a T2 SCI. This morning the client has a B/P of 210/108 and a flushed face, and complains of nasal stuffiness and a headache. The nurse responds to this assessment rapidly because of the potential for it to indicate which disorder?
A client is brought to the Emergency Department after being injured in a head-on car accident. The nurse would be most concerned about which kind of spinal cord injury?
An adult patient has sustained burns to the head, neck, and anterior trunk. Using the Lund and Browder chart, the nurse would calculate which percentage of total body surface area (TBSA) burned?
A hospital is planning construction of a new burn unit. In order to provide optimal care, which physical layout components are recommended? Select all that apply
Each patient should have a private room.
Access to the unit should be restricted.
IV replacement fluid requirements for a patient have been calculated using the Parkland formula and indicate 15,000 mL of fluid are needed. How much fluid should the patient receive per hour for the first 12 hours of therapy
A patient sustained a major burn yesterday and is being cared for in a burn unit. The nurse assesses that the patient's urine produced 40 mL of reddish-brown urine in the last hour. What action should the nurse take?
Increase the IV flow rate and notify the MD
A patient has sustained full-thickness burns over 15% of his body and is complaining of severe pain. How should the nurse interpret this information?
The margins of full-thickness burns are usually partial-thickness and are very painful.
A patient was brought to the Emergency Department by a coworker after sustaining a flame burn. What wound care priorities exist? Select all that apply
Evaluate burned extremities.
Remove any clothing that may retain heat.
Cleanse the wound with NS
patient was burned in a house fire yesterday. Which treatment of the patient's burns would the nurse question?
What nursing action is essential when providing pain management for a patient in the rehabilitative stage of burn treatment?
Regularly conduct a thorough pain Assessment
A patient who experienced severe burns a week ago is now hemodynamically stable and will be gotten out of bed for the first time. What nursing action is essential?
Apply compression wraps to the patient's lower extremities before getting him out of bed.
A nurse would assign which nursing diagnosis to any patient diagnosed with shock?
Altered tissue perfusion
A patient's SvO2 measurement is low. This suggests the nurse should provide which intervention?
Assess the patients level of pain and anxiety
A patient who is in shock will be intubated and placed on mechanical ventilation. How should the nurse explain the benefits of these actions to his family? Select all that apply.
"The mechanical ventilator will help us to give him the proper amounts of oxygen"
Maintain open airway
Reduce work having to breath
A patient presents with a 5-day history of nausea, vomiting, diarrhea, and fever. He has not been able to take fluids by mouth. The nurse provides care based on this patient's risk for which problem?
An adult patient with hypovolemic shock is given 2 liters of IV fluid. Which outcomes indicate to the nurse that the fluid is having the desired effect? Select all that apply
The patient is normotensive.
EKG reveals normal sinus rhythm
The patient is alert and oriented
A patient experienced blunt trauma to the chest in a motor vehicle crash that occurred an hour ago. Auscultation of the heart tones reveals them to be muffled. Which assessment findings would support the nurse's concern that the patient may have cardiac tamponade? Select all that apply
Systolic BP is elevated.
Distended neck veins
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