Nokea
A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?
- A. Edema at the site
- B. Severe pain at the site
- C. Epithelialization at the site
- D. Blistering at the site
Correct Answer: A
Rationale: The correct answer is A: Edema at the site. After sustaining major full-thickness burns, the body initiates an inflammatory response, leading to increased capillary permeability and fluid accumulation in the interstitial space, causing edema. This is a normal physiological response to burns. Edema helps in the healing process by providing nutrients and oxygen to the damaged tissues. Choices B, C, and D are incorrect. Severe pain may not be present initially due to nerve damage from the burn. Epithelialization typically occurs during the later stages of burn healing. Blistering is more commonly seen in partial-thickness burns rather than full-thickness burns.
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A nurse is caring for a client who has oral achalasia, The nurse should ask the client which of the following questions to assess their ability to swallow?
- A. Do you feel like you have food stuck at the base of your throat?'
- B. Do you have any feelings of fullness in the neck?'
- C. Do you feel any burning sensations in your throat?'
- D. Do you have any problems with pain while swallowing?'
Correct Answer: A
Rationale: The correct answer is A: "Do you feel like you have food stuck at the base of your throat?" This question is appropriate for assessing the client's ability to swallow because oral achalasia is a condition where the lower esophageal sphincter fails to relax, causing difficulty in passing food from the mouth to the esophagus. Asking about the sensation of food stuck in the throat helps to identify this symptom.
Choice B: "Do you have any feelings of fullness in the neck?" is incorrect because fullness in the neck is not a typical symptom of oral achalasia.
Choice C: "Do you feel any burning sensations in your throat?" is incorrect because burning sensations are more commonly associated with acid reflux or GERD, not specifically with oral achalasia.
Choice D: "Do you have any problems with pain while swallowing?" is incorrect as pain while swallowing is not a typical symptom of oral achalasia.
Therefore, the correct question to assess
A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?
- A. I should apply antibiotic ointment to the lesions.'
- B. I should use natural skin condoms during sexual intercourse.'
- C. I should expect my lesions to resolve in 6 weeks.'
- D. I should expect to take my medication for 3 weeks.'
Correct Answer: C
Rationale: The correct answer is C: "I should expect my lesions to resolve in 6 weeks." This indicates effectiveness of teaching because it shows the client understands the natural course of genital herpes and the expected timeline for resolution. Choice A is incorrect because antibiotic ointment is not recommended for herpes. Choice B is incorrect because natural skin condoms do not provide adequate protection against herpes. Choice D is incorrect because treatment duration may vary and is not always 3 weeks.
Which findings indicate the client's condition has improved? (Select all that apply)
- A. Pain level
- B. Respiratory rate
- C. Heart rate
- D. Blood pressure
- E. Echocardiogram results
- F. Urinary Output
- G. Oxygenation Saturation
Correct Answer: A, B
Rationale: The correct answers are A and B. Pain level indicates the client's subjective improvement, while respiratory rate reflects their physiological status. Pain reduction suggests improved comfort and possibly better overall health, while a decrease in respiratory rate may indicate improved oxygenation and reduced stress. Choices C, D, E, F, and G are not directly linked to the client's overall condition improvement as they can vary for several reasons, independent of the client's actual health status.
A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?
- A. Projectile vomiting
- B. Decorticate posturing
- C. Restlessness
- D. Papilledema
Correct Answer: C
Rationale: The correct answer is C: Restlessness. In early stages of increased ICP, the brain tries to compensate by increasing blood flow to maintain perfusion, leading to restlessness. Projectile vomiting (A) is a late sign due to pressure on the vomiting center. Decorticate posturing (B) and papilledema (D) are late signs of increased ICP.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice D) is common after a chest tube insertion and can be managed with pain medication.