Nokea
The nurse is planning the care for clients recovering from second- or third-degree burns. Which psychosocial nursing problem should be priority?
- A. Altered sensory perception
- B. Altered skin integrity
- C. Disturbed body image
- D. Disturbed personal identity
Correct Answer: C
Rationale: Disturbed body image occurs during the recovering stages of the burn condition and should be priority. Altered sensory perception and altered skin integrity are physiological problems. Disturbed personal identity is less likely to occur than disturbed body image.
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The nurse is caring for the client with a large, open sternal wound resulting from a burn injury. The client is receiving enteral feeding, Oxepa (an anti-inflammatory, pulmonary 1.5 Cal/mL formula), at 25 mL/hour. Which laboratory value finding best indicates that the client is receiving inadequate nutrition?
- A. Phosphorus
- B. Platelets
- C. Prealbumin
- D. Potassium
Correct Answer: C
Rationale: Prealbumin is used to evaluate nutritional status. A low level of prealbumin indicates inadequate nutrition. Prealbumin has a half-life of 2 days and reflects changes in serum protein stores more rapidly than other indices. The phosphorus level decreases in malnutrition as well as other conditions, but this is not the best indicator of inadequate nutrition. Platelets are essential to blood clotting and may or may not be altered with inadequate nutrition. Potassium is the major cation within the cell and may be low due to renal failure or GI disorders.
The ED nurse is caring for a client admitted with extensive, deep partial-thickness and full-thickness burns. Which interventions should the nurse implement? List in order of priority.
- A. Estimate the amount of burned area using the rule of nines.
- B. Insert two (2) 18-gauge catheters and begin fluid replacement.
- C. Apply sterile saline dressings to the burned areas.
- D. Determine the client’s airway status.
- E. Administer morphine sulfate, IV.
Correct Answer: D,B,E,A,C
Rationale: Priority: 1) Airway status (ABCs); 2) IV catheters/fluids (prevent shock); 3) Morphine (pain control); 4) Rule of nines (guide resuscitation); 5) Sterile dressings (infection prevention).
The nurse in a dermatology clinic is taking the history of a client. Which questions should the nurse ask the client? Select all that apply.
- A. When did you first notice the skin problem?
- B. What cosmetics or skin products do you use?
- C. Have you experienced any loss of sensation?
- D. What is your current and previous occupation?
- E. Do you experience any itching, burning, or tingling?
Correct Answer: A,B,C,D,E
Rationale: All listed questions assess onset, triggers, symptoms, and occupational exposures, critical for dermatologic history.
The nurse is assessing the client diagnosed with psoriasis. Which data would support that diagnosis?
- A. Appearance of red, elevated plaques with silvery white scales.
- B. A burning, prickling row of vesicles located along the torso.
- C. Raised, flesh-colored papules with a rough surface area.
- D. An overgrowth of tissue with an excessive amount of collagen.
Correct Answer: A
Rationale: Red plaques with silvery scales are characteristic of psoriasis. Vesicles suggest herpes zoster, papules suggest warts, and collagen overgrowth suggests keloids.
Which action is the nurse's immediate priority?
- A. Rub petroleum jelly into the burned areas.
- B. Wrap the affected areas with a clean cloth.
- C. Apply cool water to the burns.
- D. Roll the victim to smother the flames.
Correct Answer: D
Rationale: Smothering flames stops the burning process, the immediate priority.