Nokea
The nurse is caring for several clients who have burns. Which of the following persons with burns has the poorest prognosis?
- A. A 20-year-old with second- and third-degree burns over 60% of the body
- B. An 80-year-old with second- and third-degree burns over 50% of the body
- C. A 35-year-old with second- and third-degree burns over 60% of the body
- D. A 2-year-old with second- and third-degree burns over 30% of the body
Correct Answer: B
Rationale: The 80-year-old with burns over 50% has the poorest prognosis due to age-related factors, such as reduced physiological reserve and difficulty managing fluid shifts, increasing mortality risk.
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Which response will the nurse most likely observe during the caloric test if the client has Meniere's disease?
- A. Onset of severe symptoms
- B. No response or change in symptoms
- C. Improvement in balance
- D. Aphasia and loss of consciousness
Correct Answer: A
Rationale: Meniere's disease causes an exaggerated response to caloric stimulation.
The nurse is caring for the client with a burn injury. Which findings should prompt the nurse to notify the HCP because the client may be developing sepsis?
- A. Paco2 35 mm Hg and blood glucose level 250
- B. Bleeding from IV site and blood glucose level 55
- C. Temperature 103.2°F (39.6°C) and heart rate 120 bpm
- D. Respiratory rate 34 breaths/min and WBC 10,000/mm3
Correct Answer: C
Rationale: T 103.2°F (39.6°C) and HR 120 bpm may indicate that the client has sepsis. A Paco2 35 mm Hg is WNL. Hyperglycemia does occur in sepsis, but this alone is not sufficient. Abnormal clotting may occur with sepsis, but hypoglycemia does not. An RR of 34 breaths/min may indicate sepsis, but the WBC is WNL.
The nurse is caring for a client one (1) day postoperative for facial reconstruction. Which intervention should the nurse implement?
- A. Provide all activities of daily living.
- B. Allow the client to voice fears and concerns.
- C. Monitor nutritional food and fluid intake.
- D. Assess signs and symptoms of infection.
Correct Answer: D
Rationale: Assessing for infection is critical post-facial reconstruction to prevent complications. ADL provision, voicing concerns, and nutrition are secondary.
The nurse participating in a health fair is discussing malignant melanoma with a group of clients. Which information regarding the use of sunscreen is important to include?
- A. Sunscreen is only needed during the hottest hours of the day.
- B. Toddlers should not have sunscreen applied to their skin.
- C. Sunscreen does not help prevent skin cancer.
- D. The higher the number of the sunscreen, the more it blocks UV rays.
Correct Answer: D
Rationale: Higher SPF numbers block more UV rays, reducing melanoma risk. Sunscreen is needed all day, safe for toddlers, and prevents skin cancer.
The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement?
- A. This surgery will create a skin flap to cover my wounds.'
- B. This surgery will get all the old black tissue out of the wound so it can heal.'
- C. The surgery is important to allow oxygen to get to the tissue for healing to occur.'
- D. Stool will come out an opening in my abdomen so it won’t get in the sore.'
Correct Answer: D
Rationale: Fecal diversion (colostomy) prevents stool contamination of coccyx ulcers, aiding healing. Skin flaps, debridement, and oxygen delivery are unrelated to this surgery.