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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 planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
- A. Move client to a double room.
- B. Use chemical restraints at bedtime.
- C. Use a bed alarm.
- D. Encourage participation in activities that provide excessive stimulation.
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This is the most appropriate action to help prevent the client from wandering and ensure their safety. A bed alarm will alert the nurse when the client tries to get out of bed, allowing for timely intervention. Moving the client to a double room (A) may not necessarily prevent wandering. Using chemical restraints (B) is not recommended due to ethical concerns and potential adverse effects. Encouraging excessive stimulation (D) may increase agitation and wandering behavior.
A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
- A. Lethargy
- B. Hypotension
- C. Decreased heart rate
- D. Increased temperature
Correct Answer: D
Rationale: The correct answer is D: Increased temperature. In thyroid storm, there is excessive thyroid hormone production leading to hyperthyroidism symptoms, including increased body temperature. Lethargy (A) is more indicative of hypothyroidism. Hypotension (B) is not a typical finding in thyroid storm; instead, hypertension is more common. Decreased heart rate (C) is also not a common manifestation as tachycardia is typically present in thyroid storm. Therefore, option D is the most appropriate manifestation to recognize in thyroid storm.
A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the client's risk of developing breast cancer?
- A. Daily caffeine consumption
- B. A history of seasonal allergies
- C. Oral contraceptives were taken for the last 6 years
- D. Routine use of multivitamins
Correct Answer: C
Rationale: The correct answer is C. Oral contraceptives have been associated with an increased risk of breast cancer due to the hormonal changes they induce in the body. Estrogen and progesterone in oral contraceptives can promote the growth of breast cells, potentially leading to cancer. Daily caffeine consumption (A) and a history of seasonal allergies (B) are not directly linked to breast cancer development. Routine use of multivitamins (D) is generally considered beneficial for overall health and does not increase breast cancer risk.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, causing blood to back up into the systemic circulation. This leads to fluid retention, particularly in the lower extremities and abdomen, resulting in increased abdominal girth. Crackles in the lungs (A) are indicative of left-sided heart failure due to pulmonary congestion. Pink frothy sputum (C) is associated with pulmonary edema, a sign of left-sided heart failure. Hypertension (D) is not typically associated with right-sided heart failure, as it is more commonly seen in conditions like systemic hypertension.
A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
- A. Level of consciousness
- B. Surgical site
- C. Pain level
- D. Respiratory status
Correct Answer: D
Rationale: The correct answer is D: Respiratory status. In the PACU, ensuring adequate oxygenation and ventilation is crucial for the client's immediate postoperative recovery. Monitoring respiratory status helps prevent complications like hypoxia or respiratory distress. Assessing the airway, breathing rate, depth, and oxygen saturation takes precedence over other assessments. Level of consciousness (A) is important but can be affected by respiratory issues. Surgical site (B) assessment is important but not an immediate priority. Pain level (C) is important but can be managed once respiratory status is stable. Summary: Respiratory status is the priority as it directly impacts the client's immediate well-being and recovery.