Nokea
What is the primary goal of nursing care during the emergent phase after a burn injury?
- A. Replace lost fluids.
- B. Prevent infection.
- C. Control pain.
- D. Promote wound healing.
Correct Answer: A
Rationale: Replacing lost fluids is the primary goal in the emergent phase to prevent hypovolemic shock due to fluid loss from burns.
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The nurse is teaching a client with a new diagnosis of osteoporosis about dietary management. Which of the following foods should the nurse recommend?
- A. Yogurt.
- B. Bananas.
- C. White bread.
- D. Red meat.
Correct Answer: A
Rationale: Yogurt is high in calcium, essential for bone health in osteoporosis.
The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments?
- A. Interstitial compartment.
- B. Intravascular compartment.
- C. Extracellular compartment.
- D. Intracellular compartment.
Correct Answer: C
Rationale: These symptoms indicate fluid excess in the extracellular compartment, which includes interstitial spaces (edema) and intravascular spaces (contributing to lung crackles).
Which of the following assessment finding is expected in a client with bacterial pneumonia?
- A. Increased fremitus.
- B. Bilateral expiratory wheezing.
- C. Resonance on percussion.
- D. Vesicular breath sounds.
Correct Answer: A
Rationale: Increased fremitus is expected in bacterial pneumonia due to lung consolidation.
Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
- A. Polyuria, nausea, and severe headaches
- B. Polydipsia, translucent skin, and obesity
- C. Fever, tachycardia, and systolic hypertension
- D. Profuse diaphoresis, flushing, and constipation
Correct Answer: C
Rationale: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.
A client has a history of syphilis infection. The nurse interprets that the client has been re-infected when which characteristic is noted in a penile lesion?
- A. Papular areas and erythema
- B. Cauliflower-like appearance
- C. Induration and absence of pain
- D. Multiple vesicles, with some that have ruptured
Correct Answer: C
Rationale: The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Scabies is characterized by erythematous, papular eruptions. Genital warts are characterized by cauliflower-like growths, or growths that are soft and fleshy. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal.