Nokea
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
- A. Skin grafting will be done to replace damaged tissue.
- B. Large incisions will be made in the eschar to improve circulation.
- C. This is a procedure to remove dead tissue from the burn area.
- D. Escharotomy is the removal of the burned area and will not improve circulation.
Correct Answer: B
Rationale: The correct answer is B: Large incisions will be made in the eschar to improve circulation. Escharotomy involves making incisions through the eschar (dead tissue) to relieve constriction and improve circulation in the burned area. By performing escharotomy, blood flow is restored, reducing the risk of compartment syndrome and tissue necrosis.
Choice A is incorrect because skin grafting is a separate procedure done to replace damaged tissue, not part of an escharotomy. Choice C is incorrect as it describes debridement, not escharotomy. Choice D is incorrect since escharotomy aims to improve circulation rather than remove the burned area entirely.
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A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?
- A. It is caused by the lack of production of aldosterone by the adrenal gland.
- B. It is caused by a viral infection.
- C. It is caused by the overproduction of cortisol.
- D. It is caused by an autoimmune disorder.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Addison's disease is characterized by adrenal insufficiency.
2. Aldosterone is a hormone produced by the adrenal gland that helps regulate blood pressure and electrolyte balance.
3. Lack of aldosterone production in Addison's disease leads to electrolyte imbalances and low blood pressure.
4. Therefore, the correct answer is A as the lack of aldosterone production by the adrenal gland is the primary cause of Addison's disease.
Summary of other choices:
B. Addison's disease is not caused by a viral infection, so this choice is incorrect.
C. Addison's disease is not caused by the overproduction of cortisol, as it is associated with cortisol deficiency.
D. The most common cause of Addison's disease is an autoimmune disorder where the body attacks the adrenal glands, leading to their dysfunction.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated?
- A. Serum sodium
- B. Serum glucose
- C. Troponin I
- D. White blood cell count
Correct Answer: C
Rationale: The correct answer is C: Troponin I. Troponin I is a specific marker for myocardial damage. After a myocardial infarction, the damaged heart muscle releases troponin I into the bloodstream, leading to elevated levels. This helps in diagnosing and monitoring the extent of myocardial damage.
A: Serum sodium levels are not typically affected by a myocardial infarction.
B: Serum glucose levels may be elevated due to stress response but are not specific to myocardial infarction.
D: White blood cell count may be elevated in response to inflammation caused by myocardial infarction, but it is not as specific as troponin I.
A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching?
- A. Artificial lubrication can be used to treat vaginal itching and dryness.
- B. Avoid sexual activity for the first 6 months.
- C. Use a menstrual pad for vaginal bleeding.
- D. Use a diaphragm for contraception.
Correct Answer: A
Rationale: The correct answer is A: Artificial lubrication can be used to treat vaginal itching and dryness. The rationale for this is that after a total abdominal hysterectomy and bilateral salpingo-oophorectomy, there is a decrease in estrogen levels, leading to vaginal dryness and itching. Using artificial lubrication can help alleviate these symptoms and improve comfort.
Choice B is incorrect as there is no need to avoid sexual activity for 6 months unless specifically advised by the healthcare provider. Choice C is incorrect as there should not be vaginal bleeding after a total abdominal hysterectomy. Choice D is incorrect as using a diaphragm for contraception is not recommended after a hysterectomy.
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
- A. Limit salt intake.
- B. Avoid consuming alcohol.
- C. Engage in light exercise regularly.
- D. Rest frequently throughout the day.
Correct Answer: D
Rationale: The correct answer is D: Rest frequently throughout the day. For a client with hepatitis B, rest is essential to allow the body to recover and heal. Hepatitis B can cause fatigue and weakness, so resting frequently helps to conserve energy and support the immune system in fighting the infection. Limiting salt intake (Choice A) is not directly related to managing hepatitis B. Avoiding alcohol (Choice B) is important but more for liver health in general, not specifically for hepatitis B. Engaging in light exercise regularly (Choice C) may be beneficial for overall health, but during active hepatitis B infection, rest is more crucial.
A nurse is teaching a group of newly licensed nurses on effective techniques for counseling clients about sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?
- A. Ask about the client's exposure to any past or present STIs.
- B. Advise clients not to disclose their sexual history.
- C. Focus only on present symptoms of STIs.
- D. Only ask about high-risk behavior.
Correct Answer: A
Rationale: The correct answer is A because asking about the client's exposure to any past or present STIs is crucial for effective counseling. Understanding the client's history helps in assessing risk factors, determining appropriate interventions, and providing tailored education. It also promotes trust and open communication.
Choice B is incorrect as advising clients not to disclose their sexual history hinders the nurse's ability to provide comprehensive care and support. Choice C is incorrect because focusing only on present symptoms may overlook important information needed for proper assessment and management. Choice D is incorrect as only asking about high-risk behavior limits the scope of the assessment and may miss potential risk factors.