Nokea
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
- A. Fluid volume deficit secondary to alteration in skin integrity
- B. Alteration in comfort secondary to alteration in skin integrity
- C. Alteration in sensation secondary to third-degree burn
- D. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
Correct Answer: D
Rationale: Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
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The nurse would expect to include which of the following when planning the management of the client with Lyme disease?
- A. Complete bed rest for 6-8 weeks
- B. Tetracycline treatment
- C. IV amphotericin B
- D. High-protein diet with limited fluids
Correct Answer: B
Rationale: The client is not placed on complete bed rest for 6 weeks. Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. IV amphotericin B is the treatment for histoplasmosis. The client is not restricted to a high-protein diet with limited fluids.
Primary nursing diagnoses for the antisocial client are:
- A. Alteration in perception and altered self-concept
- B. Impaired social interaction, ineffective individual coping, and altered self-concept
- C. Altered communication processes and altered recreational patterns
- D. Altered body image and altered thought processes
Correct Answer: B
Rationale: This answer is incorrect. Perception is not altered because the client is not psychotic. This answer is correct. The antisocial client lacks responsibility, accountability, and social commitment; has impaired problem-solving ability; tends to overuse defense mechanisms; lies and steals; and is often grandiose concerning self. This answer is incorrect. Altered communication processes do not characterize this client. The antisocial person communicates well and tends to have a charming personality. This answer is incorrect. Altered thought processes refer to delusional thinking, which is bizarre and fixed, and do not characterize this client.
A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, 'Isn't that a lot?' The nurse's best response is:
- A. Yes, that does seem like a lot.'
- B. You'll have to talk to the doctor about that. The physician knows what's best for the client.'
- C. Six to 10 treatments are common. Are you concerned about permanent effects?'
- D. Don't worry. Some clients have lots more than that.'
Correct Answer: C
Rationale: The most common range for affective disorders is 6-10 treatments. This response confirms and reinforces the physician's plan for treatment. It also opens communication with the husband to identify underlying fears and knowledge deficits.
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for cesarean delivery
- D. Administer tocolytics
Correct Answer: A
Rationale: Postpartum endometritis is treated with antibiotics to address the uterine infection. Fetal heart tones are irrelevant postpartum cesarean delivery is not indicated and tocolytics are for preterm labor.
A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following?
- A. Start the child on solid food.
- B. Nurse the child more frequently during this growth spurt.
- C. Provide supplements for the child between breastfeeding so you will have enough milk.
- D. Wait 4 hours between feedings so that your breasts will fill up.
Correct Answer: B
Rationale: Solid foods introduced before 4-6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. Supplementation will decrease the infant's appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother's body to produce a correspondingly increased amount of milk.