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During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the client's chest. Which descriptors should the nurse use to document these observations?
- A. Clustered and annular
- B. Linear and circinate
- C. Diffuse and serpiginous
- D. Coalesced and circumscribed
Correct Answer: C
Rationale: Diffuse is used to describe lesions that are widespread. Serpiginous describes lesions with wavy borders.
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A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?
- A. Increase intravenous fluids by 100 mL/hr.
- B. Administer furosemide (Lasix) 40 mg IV push.
- C. Continue to monitor urine output hourly.
- D. Draw blood for serum electrolytes STAT.
Correct Answer: B
Rationale: Furosemide is inappropriate as it would worsen fluid loss in a burn client needing increased fluids.
The nurse working with children knows which burn is the most common type of burn in the pediatric population?
- A. Contact
- B. Flame
- C. Scald
- D. Thermal
Correct Answer: C
Rationale: Scald burns, caused by hot liquids or steam, are the most common in children due to their curiosity and lack of coordination (e.g., pulling hot water off stoves). 'Thermal' is a broad category, but scalds are specifically frequent.
An African-American male is discussing his dietary intake with the nurse. The nurse encourages the client to keep sodium intake below 1,500 mg per day. The client reports he does not have any known risk for the development of hypertension and feels this is too restrictive. How should the nurse respond?
- A. African-Americans typically have higher sodium levels than their Caucasian counterparts.'
- B. This is the amount of sodium intake recommended for everyone.'
- C. This is what will be best for you.'
- D. Do you eat a great deal of salt?'
Correct Answer: A
Rationale: After generations of conditioning, African-Americans frequently have higher sodium levels. The recommended sodium intake for African-Americans is slightly lower than for their Caucasian peers. Simply telling the client the recommendation is 'best' does not provide adequate information. The amount of salt ingested should be recorded, but this is not the best response.
If a man burns his total left arm and half of the front of his chest, what percentage of his body is burned?
- A. 9%
- B. 18%
- C. 27%
- D. 36%
Correct Answer: B
Rationale: Using the Rule of Nines: left arm = 9%, half of anterior chest = 9% (full chest = 18%), total = 18%.
The client diagnosed with male pattern baldness is prescribed finasteride. When should the nurse evaluate for effectiveness of the medication?
- A. After the client has been taking the medication for 1 month.
- B. When the client states there are no hair strands in the comb.
- C. At the time the client's hair changes texture and color.
- D. One year after taking the hair growth stimulant medication daily.
Correct Answer: D
Rationale: Finasteride requires up to 1 year to assess hair regrowth (effective in 50% of cases). One month is too soon, comb findings and texture/color changes aren't reliable indicators.