Nokea
The nurse is caring for the immobile client who is at risk for developing pressure ulcers. Which food should the nurse recommend?
- A. Assorted fruit salad
- B. Oatmeal with raisins
- C. Baked chicken breast
- D. Lettuce and tomato salad
Correct Answer: C
Rationale: Chicken is a high-protein food. Proteins are needed to help meet the body's needs for tissue repair and to maintain skin integrity. Fruit salad, oatmeal, and lettuce salad are high-fiber or carbohydrate foods, not high in protein.
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The nurse who documents the burn injury is accurate in identifying the full-thickness burns as having what appearance?
- A. White and leathery
- B. Pink and blistered
- C. Red and painful
- D. Mottled and wet
Correct Answer: A
Rationale: Full-thickness burns appear white, leathery, and painless due to nerve destruction.
The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client’s mental health?
- A. Encourage the client to stay at home as much as possible.
- B. Discuss the importance of not relying on the family for needs.
- C. Tell the client to remember that changes in lifestyle take time.
- D. Instruct the client to discuss feelings only with the therapist.
Correct Answer: C
Rationale: Acknowledging lifestyle changes promotes mental health by fostering realistic expectations. Isolation, independence from family, or limiting discussions hinder recovery.
A woman who has herpes simplex 1 (HSV1) around the mouth and nose asks the nurse if she can give the sores to her husband. What should the nurse include when answering this client?
- A. Herpes simplex 1 (HSV1) is a fever blister and is not contagious.
- B. She should not kiss her husband or anyone else because it can be transmitted to susceptible persons.
- C. Fever blisters are seen only in persons who have fevers.
- D. The virus is transmitted through coughing and sneezing.
Correct Answer: B
Rationale: HSV1 is contagious and can be transmitted through direct contact, such as kissing, especially during active outbreaks.
The nurse is planning care for a newly burned client. What is the priority nursing observation to be made during the first 48 hours after the burn?
- A. Hourly blood pressure
- B. Assessment of skin color and capillary refill
- C. Hourly urine measurement
- D. Frequent assessment for pain
Correct Answer: C
Rationale: Hourly urine measurement is critical in the first 48 hours to monitor fluid resuscitation effectiveness and prevent hypovolemic shock.
The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm × 4 cm stage II on the coccyx. Which information would alert the nurse that the client’s pressure ulcer is getting worse?
- A. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch.
- B. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally.
- C. The skin covering the coccyx is intact but the client complains of pain in the area.
- D. The coccyx wound extends to the subcutaneous layer and there is drainage.
Correct Answer: D
Rationale: Extension to the subcutaneous layer with drainage indicates progression to stage III or IV, worsening the ulcer. Smaller size, blisters, or pain are less severe.