Nokea
An adult client is admitted to the emergency department after a burn injury. The burn initially affected the upper half of the client's anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran causing subsequent burn injuries to the entire face (anterior half of the head), and the upper half of the posterior torso. Using the rule of nines, the extent of the burn injury would be what percent?
Correct Answer: 31.50%
Rationale: According to the rule of nines, with the initial burn, the upper half of the anterior torso equals 9% and the lower half of both arms equals 9%. The subsequent burn included the anterior half of the head equaling 4.5% and the upper half of posterior torso equaling 9%. This totals 31.5%.
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On the night before a 58-year-old wife and mother is to have a lobectomy for lung cancer, she remarks to the nurse, 'I am so scared of this cancer. I should have quit smoking years ago. Now I've brought all this fear and sadness on myself and now my family.' The nurse should tell the client:
- A. It's normal to be scared. I would be, too. We'll help you through it.'
- B. Do you feel guilty because you smoked?'
- C. Don't be so hard on yourself. You don't know if your smoking caused the cancer.'
- D. I can imagine how scared you are. What is it about cancer that you're afraid of?'
Correct Answer: D
Rationale: Acknowledging the client's fear and exploring specific concerns fosters therapeutic communication, helping address her emotions effectively.
The charge nurse determines that the new nurse understands the concepts associated with suicide and suicide intentions when the new nurse makes which statement?
- A. Only the psychotic individual commits suicide.
- B. Suicidal attempts are attention-seeking behaviors.
- C. Suicide runs in the family, so there is nothing that health care personnel can do about it.
- D. Many individuals who commit suicide have talked about their suicidal intentions to others.
Correct Answer: D
Rationale: Most people who do commit suicide have given definite clues or warnings about their intentions. The individual who is suicidal is not necessarily psychotic. A suicide attempt is not an attention-seeking behavior, and each act should be taken very seriously. Suicide is not an inherited condition. The remaining options are considered myths regarding suicide.
A client with a history of type 2 diabetes is prescribed glipizide (Glucotrol). The nurse should instruct the client to:
- A. Take the medication 30 minutes before meals.
- B. Avoid alcohol consumption.
- C. Take the medication at bedtime.
- D. Stop the medication if blood glucose normalizes.
Correct Answer: A, B
Rationale: Glipizide should be taken 30 minutes before meals to optimize glucose control, and alcohol should be avoided to prevent hypoglycemia.
The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply.
- A. Normal blood pressure.
- B. Generalized edema.
- C. Normal serum lipid levels.
- D. No red blood cells in the urine.
- E. Elevated streptococcal antibody titers.
Correct Answer: B,D
Rationale: Nephrotic syndrome is characterized by generalized edema and no red blood cells in the urine. Blood pressure may be elevated, serum lipids are typically high, and streptococcal antibodies are not typically associated.
The nurse is assessing a client with suspected appendicitis. Which of the following findings would support this diagnosis?
- A. Pain at McBurney's point.
- B. Decreased bowel sounds.
- C. Bradycardia.
- D. Fever of 99°F.
Correct Answer: A, B
Rationale: Pain at McBurney's point and decreased bowel sounds are classic signs of appendicitis due to peritoneal irritation and intestinal obstruction.