Nokea
The client with a burn injury is assessed using the 'rule of nines' to determine which of the following?
- A. Amount of body surface area burned.
- B. Rehabilitation needs.
- C. Respiratory needs.
- D. Type of intravenous fluids required.
Correct Answer: A
Rationale: The rule of nines estimates the percentage of body surface area burned to guide treatment.
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Select the sound that is heard with percussion with its description.
- A. Tympany: A hollow sound
- B. Dullness: A thud like sound
- C. Dullness: A hollow sound
- D. Resonance: A booming sound
Correct Answer: A,B,D
Rationale: Tympany is a hollow sound (e.g., over air-filled structures like the stomach), dullness is a thud-like sound (e.g., over solid organs like the liver), and resonance is a booming sound (e.g., over lung tissue). Option C is incorrect because dullness is not a hollow sound.
A female client with paranoid schizophrenia has been hearing negative voices and 'getting special messages from various sources,' which of the following interventions is most appropriate for the client's symptoms?
- A. Asking her to make simple decisions
- B. Being matter-of-fact with her
- C. Monitoring her reactions to television programs
- D. Reinforcing appropriate dress and hygiene
Correct Answer: B
Rationale: Being matter-of-fact helps ground a client with paranoid schizophrenia, reducing misinterpretations of reality. Decision-making, TV monitoring, or hygiene reinforcement are less directly related to auditory hallucinations.
A client with a history of epilepsy is prescribed carbamazepine (Tegretol). The nurse should monitor the client for which of the following adverse effects?
- A. Agranulocytosis.
- B. Hypernatremia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Carbamazepine can cause agranulocytosis, requiring monitoring of white blood cell counts.
A child's plan of care lists increasing protein intake as a goal. Which of the following foods that the child likes should the nurse encourage the child to eat?
- A. A bacon, lettuce, and tomato sandwich.
- B. Fruit-flavored yogurt.
- C. Nacho chips and salsa.
- D. Crackers with butter and jelly.
Correct Answer: B
Rationale: Fruit-flavored yogurt is a good source of protein, suitable for increasing protein intake in a child's diet.
A client is admitted to the hospital with the diagnosis of Cushing's disease. The nurse should monitor the client's laboratory studies for which associated disorder?
- A. Hypokalemia
- B. Hyperglycemia
- C. Decreased plasma cortisol levels
- D. Low white blood cell (WBC) count
Correct Answer: B
Rationale: The client with adrenocorticosteroid excess experiences hyperglycemia, hyperkalemia, elevated plasma cortisol and adrenocorticotropic hormone (ACTH) levels, and an elevated WBC count. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids on the body.