Nokea
A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?
- A. Within 12 hours after burn trauma
- B. 24 to 36 hours after burn trauma
- C. 36 to 48 hours after burn trauma
- D. 48 to 72 hours after burn trauma
Correct Answer: A
Rationale: In a burn injury, usually the greatest fluid loss occurs within the first 12 hours.
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The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in this guide indicate?
- A. Severity of the symptoms
- B. Site of the lesions
- C. Symptomatology of the lesions
- D. Surface area of the lesions
Correct Answer: A
Rationale: The mnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body, Severity of the symptoms, Time (length of time the disorder has been present). In this mnemonic, S does not stand for site, symptomology or surface area of the lesion.
Which patient instruction will the nurse reinforce relative to the management of systemic lupus erythematosus (SLE)?
- A. Maintain a balance between rest and activity.
- B. Increase activity to promote mobility.
- C. Increase exposure to the sun to increase vitamin D absorption.
- D. Increase sodium consumption.
Correct Answer: A
Rationale: Balanced rest, activity, and diet will support medication management. It is not necessary to increase activity to promote mobility. Limited sunlight exposure is recommended to prevent photosensitivity. SLE often has kidney involvement, which would require reduction of sodium.
A nurse can assess cyanosis in a dark-skinned patient by assessing the color of which body part?
- A. abdomen
- B. sclera.
- C. lips and mucous membranes.
- D. soles of the feet.
Correct Answer: C
Rationale: Assessment of color is more easily made in areas where the epidermis is thin, such as the lips and mucous membranes. Assessing the abdomen, sclera or soles of the feet will not be as accurate as the lips and mucous membranes.
A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for which most common cause of burn-related deaths?
- A. shock.
- B. respiratory arrest.
- C. hemorrhage.
- D. infection.
Correct Answer: D
Rationale: Infection is the most common complication and cause of death after the first 72 hours. Shock, due to hypovolemia is most common during the emergent phase of the burn injury. Respiratory arrest and hemorrhage are not common causes of death.
A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?
- A. Angioma
- B. Keloid
- C. Melanoma
- D. Nevus
Correct Answer: B
Rationale: Keloids, which originate in scars, are hard and shiny and are seen more often in African Americans than in Whites. An angiomas resembles a birthmark. A melanoma is a serious form of skin cancer. A nevus is commonly referred to as a mole.