Nokea
A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?
- A. Maintain calorie intake at 1,500 per day
- B. Provide a low-protein, high-carbohydrate diet.
- C. Keep a calorie count for foods and beverages.
- D. Schedule meals at 6-hr intervals
Correct Answer: C
Rationale: The correct answer is C: Keep a calorie count for foods and beverages. For a client with major burn injuries, accurate monitoring of calorie intake is crucial to support nutritional requirements for wound healing and metabolic demands. This intervention allows the nurse to adjust the diet as needed to meet the client's energy needs. Choice A is incorrect as calorie intake requirements may vary based on individual needs. Choice B is incorrect as a high-protein diet is essential for wound healing in burn patients. Choice D is incorrect as frequent, smaller meals are typically recommended for burn patients to support healing and prevent muscle breakdown.
You may also like to solve these questions
A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?
- A. An induration measuring 10 mm
- B. An induration measuring 5 mm
- C. A reddened area measuring 10 mm
- D. A reddened area measuring 5 mm
Correct Answer: A
Rationale: The correct answer is A: An induration measuring 10 mm. An induration of 10 mm or greater is considered a positive result for a tuberculin skin test in individuals who are at higher risk for tuberculosis. This indicates exposure to the tuberculosis bacteria and an immune response. Choices B, C, and D are incorrect because the presence of redness or a smaller induration size does not meet the criteria for a positive test result. Redness alone does not signify a positive result, and a smaller induration size is not indicative of a positive test. It is important to interpret tuberculin skin tests accurately to guide further testing and treatment decisions.
A nurse is providing an in service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who uses a wheelchair and is confused
- B. A client who is bedridden and wears a hearing aid
- C. A client who is ambulatory and receiving oxygen
- D. A client who has a fracture and is in balance suspension traction
Correct Answer: A
Rationale: The correct answer is A because a client who uses a wheelchair and is confused is at the highest risk during a fire evacuation due to mobility limitations and decreased ability to follow instructions. Evacuating this client first ensures their safety and prevents potential delays in the evacuation process.
Choice B is incorrect because a bedridden client wearing a hearing aid can still be safely evacuated with assistance. Choice C is incorrect as an ambulatory client receiving oxygen can usually move independently and should be evacuated after the client in a wheelchair. Choice D is incorrect because a client with a fracture in traction can be safely moved with proper equipment and should not be the first priority for evacuation.
A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. Self-centered behavior
- D. Violates other's rights
Correct Answer: C
Rationale: The correct answer is C: Self-centered behavior. Individuals with histrionic personality disorder typically exhibit attention-seeking, dramatic, and overly emotional behaviors. They often crave approval and validation from others, focusing on themselves and their own needs. This behavior aligns with the core characteristics of histrionic personality disorder.
Choice A (Suspicious of others) is incorrect as suspicion is not a defining trait of histrionic personality disorder. Choice B (Callousness) is inconsistent as histrionic individuals tend to be overly emotional rather than callous. Choice D (Violates other's rights) is not a common feature of histrionic personality disorder.
In summary, the nurse should expect self-centered behavior in a client with histrionic personality disorder, as they typically display attention-seeking and dramatic behaviors, seeking validation and approval from others.
A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender?
- A. The client has a history of alcohol use disorder
- B. The client has a history of asthma.
- C. The client takes vitamin C daily
- D. The client takes furosemide twice daily
Correct Answer: B
Rationale: The correct answer is B. Lavender oil can exacerbate asthma symptoms due to its potential to irritate the respiratory system. Asthma is a contraindication because it can trigger or worsen asthma attacks. Alcohol use disorder (A), vitamin C intake (C), and furosemide use (D) are not contraindications for using lavender oil. Alcohol use disorder does not directly interact with lavender oil. Vitamin C intake and furosemide use do not have known interactions with lavender oil that would contraindicate its use.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following hip replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction helps prevent slipping and falling, which is crucial for a postoperative hip replacement patient. Rubber-backed rugs provide stability and reduce the risk of accidents. Option A is incorrect as wearing shoes at home can increase the risk of falls. Option B is incorrect as placing a throw rug over electrical cords can lead to tripping hazards. Option C is incorrect as marking doorways with tape does not address home safety concerns for a postoperative patient.