Nokea
Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely?
- A. Curling ulcer
- B. Paralytic ileus
- C. Ruptured colon
- D. Gastritis
Correct Answer: A
Rationale: Curling ulcer is a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body. The first sign is usually vomiting of bright red blood. Paralytic ileus involves the small intestine becoming immobile, characterized by absent bowel sounds. A ruptured colon would cause internal bleeding, and possibly rectal bleeding. Gastritis would not cause bright red bleeding.
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A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for which most common cause of burn-related deaths?
- A. shock.
- B. respiratory arrest.
- C. hemorrhage.
- D. infection.
Correct Answer: D
Rationale: Infection is the most common complication and cause of death after the first 72 hours. Shock, due to hypovolemia is most common during the emergent phase of the burn injury. Respiratory arrest and hemorrhage are not common causes of death.
Which is a common diagnostic criterion for identifying systemic lupus erythematosus (SLE)?
- A. Butterfly rash over nose and cheeks
- B. Photosensitivity
- C. Severe abdominal pain
- D. Skin ulcers
- E. Polyarthralgias and polyarthritis
- F. Immobility
Correct Answer: A,B,E
Rationale: Butterfly rash on face, sensitivity to sunlight, polyarthralgias, and polyarthritis are some of the main criteria leading to the diagnosis of SLE. Abdominal pain, skin ulcers and immobility are not associated with SLE.
Which is a nursing intervention and patient teaching item for the treatment of head lice and scabies?
- A. Clothing, linens, and bath articles thoroughly cleaned in hot water
- B. Stress nature and transmission of the disease
- C. Special carbohydrate diet to promote healing
- D. Complete isolation from the public
- E. removal of pets from the home
Correct Answer: A,B
Rationale: Identify involved contacts while stressing importance of preventing transmission of disease. Washable and clothing items should be cleaned in hot water to prevent reinfection. No special diet is required. Isolation is not necessary once medical management is completed. It is not necessary to remove pets from the home.
During primary survey of a patient who sustained a burn injury, the nurse checks for which as an early signs of carbon monoxide poisoning?
- A. Dizziness
- B. Urticaria
- C. Vomiting
- D. Headache
- E. Vertigo
- F. Unsteady gait
Correct Answer: C,D,F
Rationale: Early signs of carbon monoxide poisoning include headache, nausea, vomiting, and unsteady gait. Urticaria is a skin reaction seen in allergic responses. Dizziness and vertigo are not signs of carbon monoxide poisoning.
A patient has sustained a burn injury following a house fire. Which finding indicates the need to observe the patient for airway complications?
- A. Bradypnea
- B. Singed nasal hairs
- C. Burns to the upper arms
- D. Intercostal retractions
- E. Grunting noted with respiration
Correct Answer: B,D,E
Rationale: A patient who has sustained a burn injury should be monitored for airway complications if the patient has singed nasal hairs, intercostal retractions or grunting respirations. Tachypnea, not bradypnea, is a finding suggestive of potential airway complications. A patient with burns to the face, neck and upper chest requires further observation.