Nokea
A child has been in the burn unit for 13 days. Which nursing assessment indicates that a priority goal has been met?
- A. Decreased albumen over 5 days
- B. Intake equals output for 24 hours
- C. Participates in dressing changes
- D. Weight gain of 0.5 kg in 1 week
Correct Answer: D
Rationale: Nutrition is an important problem for the child with burns, as the child is hypermetabolic and needs a high-calorie, high-protein diet. Children are generally weighed twice a week in the burn center. A weight gain shows that nutritional needs are being met.
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The nurse is collecting data during a routine clinic visit. The client reports she has experienced bleeding between her menstrual periods. What initial action by the nurse is most appropriate?
- A. Determine the timing of the bleeding episodes.
- B. Determine the amount of the bleeding episodes.
- C. Assess for the presence of sexually transmitted infections.
- D. Review the length of the client's normal menstrual cycles.
Correct Answer: A
Rationale: Timing of bleeding helps identify causes (e.g., midcycle ovulation). Amount and other assessments follow this initial step.
A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. Which of the following is the most plausible explanation for this patient's signs and symptoms?
- A. Subluxated right hip
- B. Right hip contusion
- C. Hip strain
- D. Traumatic hip dislocation
Correct Answer: D
Rationale: Signs and symptoms of a traumatic dislocation include acute pain, change in positioning of the joint, shortening of the extremity, deformity, and decreased mobility. A subluxation would cause moderate deformity, or possibly no deformity. A contusion or strain would not cause obvious deformities.
The nurse is caring for a dark-skinned African American patient. Which site should the nurse use to evaluate for the presence or absence of cyanosis?
- A. Sclera
- B. Nail beds
- C. Hard palate
- D. Inner aspect of the arm
Correct Answer: B
Rationale: Nail beds show cyanosis as a bluish cast, reliable in dark skin where skin tone may mask changes.
Which type of capillary hemangioma is described by the following: this is a common blemish on the head and neck of a newborn child and rapidly disappears spontaneously
- A. Strawberry naevus
- B. Port-wine stain
- C. Campbell de Morgan spots
- D. Spider naevus
Correct Answer: A
Rationale: Strawberry nevus typically appears on the head and neck of newborns and tends to disappear spontaneously.
A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?
- A. Come to the emergency department.
- B. Apply calamine lotion immediately to the exposed skin areas.
- C. Take a shower immediately, lathering and rinsing several times.
- D. It is not necessary to do anything if you cannot see anything on your skin.
Correct Answer: C
Rationale: Washing off the urushiol oil from poison ivy prevents the rash from developing.