Nokea
When examining the electrical burn on the victim, which assessment is most important for the nurse to determine?
- A. The entry and exit wound sites
- B. Degree of skin discoloration
- C. Amount of eschar on the wound bed
- D. Characteristics of wound drainage
Correct Answer: A
Rationale: Identifying entry and exit sites assesses the extent of internal tissue damage.
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The client with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal?
- A. The client will refrain from scratching the skin.
- B. The client will maintain intact skin integrity.
- C. The client will have relief from itching.
- D. The client will not develop a secondary bacterial infection.
Correct Answer: B
Rationale: Maintaining intact skin integrity is a long-term goal, preventing complications from viral lesions. Refraining from scratching, itch relief, and infection prevention are interventions.
Which statement by the nurse most accurately explains the pathophysiology of conductive hearing loss?
- A. Sound waves do not travel to the inner ear.
- B. There is a malfunction of inner ear structures.
- C. The auditory nerve does not transmit sound to the brain.
Correct Answer: A
Rationale: Conductive hearing loss occurs when sound waves are blocked from reaching the inner ear.
Once the victim's blood pressure is stabilized, the best indication of successful response to the initial burn treatment is which assessment finding?
- A. Normal body temperature
- B. Minimal level of pain
- C. Adequate urine output
- D. Ability to perform exercises
Correct Answer: C
Rationale: Adequate urine output indicates successful fluid resuscitation.
Which nursing intervention is most appropriate to include in the care plan of an anxious client who is blind or has the eyes patched?
- A. Touch the client before speaking.
- B. Explain what you plan to do beforehand.
- C. Stand in front of the client when speaking.
- D. Leave the room lights on at all times.
Correct Answer: B
Rationale: Explaining actions beforehand reduces anxiety by preparing the client for what to expect.
The nurse identifies the concept of impaired skin integrity for a pediatric client diagnosed with impetigo on the arms. Which interventions should the nurse implement?
- A. Teach the parents to ensure the child takes all the prescribed antibiotics.
- B. Give the parents a written excuse so the child can go back to school.
- C. Encourage the parents to bathe the child in an oatmeal bath for the itching.
- D. Apply topical lidocaine before debriding the crusts from the lesions.
Correct Answer: A
Rationale: Completing antibiotics ensures impetigo resolution, addressing skin integrity. School return requires clearance, oatmeal baths are for comfort, and lidocaine is unnecessary.