Nokea
An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?
- A. Apply ice packs to both legs.
- B. Begin débridement by removing all charred clothing from wound.
- C. Apply Silvadene cream (silver sulfadiazine).
- D. Immerse both legs in cool water.
Correct Answer: D
Rationale: Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.
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A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:
- A. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids
- B. Is available at discount pharmacies for a reduced price
- C. Is usually not necessary after the first year following transplantation
- D. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually resolve themselves
Correct Answer: A
Rationale: Cyclosporine is the immunosuppressive drug of choice. It provides immunosuppression but does not lower the white blood cell count; therefore, the client is less susceptible to infection. Cyclosporine is available at discount pharmacies. The cost may be absorbed by health insurance, or Medicare, if the client is eligible. However, this statement does not address the entire problem verbalized by the client. Immunosuppressive agents will be taken for the client's entire life because rejection can occur at any time. These side effects do not necessarily resolve in time; however, the client may adapt.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: Nosebleeds in preeclampsia may indicate severe hypertension or coagulopathy, requiring immediate reporting. Pedal edema is common, bed rest is not always needed, and sodium restriction is secondary.
A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurse's discharge teaching should include:
- A. Telling the client's wife not to touch the tablets
- B. Explaining that the medication should be taken with meals
- C. Telling the client that symptoms will improve in 1-2 weeks
- D. Instructing the client to take the medication at bedtime, to prevent nocturia
Correct Answer: A
Rationale: Finasteride tablets should not be handled by pregnant women due to the risk of fetal harm. Symptom improvement takes months, not weeks, and the medication can be taken with or without food or at any time.
A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, 'I haven't exercised in 6 days. I won't be eating lunch today.' This statement by her most likely reflects:
- A. Her lack of internal awareness about the outcome of the behavior
- B. Increased knowledge about personal exercise plans
- C. A manipulative technique to trick the nurse into allowing her to miss a meal
- D. A true desire to stay fit while in the hospital
Correct Answer: A
Rationale: Indirect self-destructive behavior such as that seen in anorexia nervosa is characterized by the client's lack of insight and the awareness that the outcome of the dieting, exercising, and weight loss will ultimately result in death if uninterrupted.
The nurse is caring for a client with a diagnosis of postpartum hemorrhage. Which vital sign change is most likely to be observed?
- A. Tachycardia
- B. Hypotension
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Postpartum hemorrhage causes significant blood loss leading to tachycardia (to compensate for reduced volume) and hypotension (from decreased perfusion). Both are common vital sign changes.