Nokea
During the Emergent phase of a burn, the most fatal electrolyte imbalance in a burned client is:
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hyponatremia
Correct Answer: A
Rationale: During the Emergent phase of burns, the most fatal electrolyte imbalance is Hypokalemia. This is due to the shift of potassium from the intracellular space to the extracellular space, leading to low potassium levels in the blood. Choices B, C, and D are incorrect because Hyperkalemia, Hypernatremia, and Hyponatremia are not typically associated with the Emergent phase of burns and do not pose the same level of risk as Hypokalemia in this context.
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When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:
- A. Amount of food and fluid taken during the last meal before treatment
- B. Respiratory rate, breath sounds, and location of congestion
- C. Teaching the client's relatives to perform the procedure
- D. Doctor's order regarding position restrictions and client's tolerance for lying flat
Correct Answer: B
Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.
Being in contact with reality and the environment is a function of the:
- A. conscience
- B. ego
- C. id
- D. super ego
Correct Answer: B
Rationale: Being in contact with reality and the environment is a function of the ego. The ego is responsible for mediating between the id's basic desires, the superego's idealistic standards, and the real world. The conscience (not listed as a choice) is related to feelings of guilt or moral responsibility. The id represents primal instincts, and the superego represents the internalized ideals and moral standards.
A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:
- A. perfusion
- B. locomotion
- C. respiration
- D. mentation
Correct Answer: D
Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.
A client who was normal weight before pregnancy asks about the recommended weight gain during pregnancy. What should the nurse advise?
- A. 18-40 pounds
- B. 25-35 pounds
- C. 11-20 pounds
- D. 15-25 pounds
Correct Answer: B
Rationale: The correct answer is B: 25-35 pounds. According to standard prenatal guidelines, a client with a normal pre-pregnancy weight is recommended to gain between 25-35 pounds during pregnancy. This weight gain is important for the overall health of the mother and the developing baby. Choices A, C, and D are incorrect because they do not fall within the recommended weight gain range for a client with a normal pre-pregnancy weight.
This study, which is an in-depth study of one boy, is a:
- A. case study
- B. longitudinal study
- C. cross-sectional study
- D. evaluative study
Correct Answer: A
Rationale: The correct answer is 'A: case study.' A case study involves an in-depth examination of a single individual, group, or event. In this scenario, focusing on one boy aligns with the definition of a case study. The other options are not applicable: B) A longitudinal study involves following subjects over a period of time, C) A cross-sectional study examines a population at a single point in time, and D) An evaluative study assesses the effectiveness of a program or intervention, which is not the focus of the given scenario.