Nokea
A female client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid exercise because it may:
- A. Dislodge the autografts.
- B. Increase pain unnecessarily.
- C. Cause excessive swelling.
- D. Delay wound healing.
Correct Answer: A
Rationale: Early exercise can dislodge autografts before they fully adhere, compromising graft success.
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Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison's disease?
- A. Discuss the importance of tapering medications when discontinuing medication
- B. Explain the dose may need to be increased during times of stress or infection
- C. Instruct the client to take medication on an empty stomach with a glass of water
- D. Encourage the client to wear clean white socks when wearing tennis shoes
Correct Answer: B
Rationale: Stress or infection increases cortisol demand; dose adjustment prevents adrenal crisis.
The elderly client diagnosed with poison ivy is prescribed a solumedrol (a steroid) dose pack. Which intervention should the nurse teach the client?
- A. Tell the client to return to the office in one (1) week for blood levels.
- B. Instruct the client to take the medication exactly as prescribed.
- C. Explain the medication should be taken on an empty stomach.
- D. Teach to stop the medication immediately if side effects occur.
Correct Answer: B
Rationale: Adherence to the prescribed steroid taper is crucial for efficacy and to avoid adrenal suppression.
A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
- A. Assess the level of consciousness and pupillary reactions.
- B. Ascertain the time food or liquid was last consumed.
- C. Auscultate breath sounds over the trachea and bronchi.
- D. Measure abdominal girth and auscultate bowel sounds.
Correct Answer: C
Rationale: Drooling and difficulty swallowing suggest an inhalation injury; auscultating breath sounds assesses airway patency.
The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?
- A. A urinary output of 50 mL/hour
- B. A coagulation time of 5 minutes
- C. A heart rate that is 90 beats/minute and irregular
- D. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L)
Correct Answer: C
Rationale: Pheochromocytoma causes catecholamine excess, potentially leading to irregular heart rate and hypertensive crisis, a serious complication, unlike the other normal findings.
The nurse notes a thickening and hardening of the skin from continued irritation on an individual who is wheelchair-bound. What term should the nurse use to describe this finding?
- A. Crust
- B. Papule
- C. Excoriation
- D. Lichenification
Correct Answer: D
Rationale: Lichenification is thickened, hardened skin. A crust is a scab formed by dried serum. A papule is a raised solid lesion. Excoriation is a traumatic abrasion.