Nokea
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.
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The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?
- A. Increase the IV rate and monitor for burn shock.
- B. Monitor for signs of seizure activity.
- C. Assess for signs of fluid overload.
- D. Raise the foot of the bed and apply blankets.
Correct Answer: C
Rationale: As the blood volume increases, the cardiac output increases to increase renal perfusion. The result includes diuresis. However, a great risk for the patient includes fluid overload because of the rapid movement of fluid back into the intravascular space. Burn shock occurs from hypovolemia in the first 72 hours of a burn injury. Seizures are not associated with the burn injury. Raising the foot of the bed would not be of value in this situation.
What is the last intervention for a hospitalized severely burned victim during the emergent phase?
- A. Tetanus prophylaxis.
- B. Insert Foley catheter.
- C. Insert nasogastric tube.
- D. Establish airway.
- E. Administer analgesics.
- F. Initiate fluid therapy.
Correct Answer: A,
Rationale: The priority of care should proceed from the establishment of an airway,initiation of fluid therapy,insertion of Foley and NG tube administration of analgesics and tetanus prophylaxis."
The nurse has staged a pressure injury that has a shallow crater with a dry pink wound bed in which way?
- A. stage 1.
- B. stage 2.
- C. stage 3.
- D. stage 4.
Correct Answer: B
Rationale: Stage 2 pressure injuries appear as a shallow open injury, usually shiny or dry, with a red-pink wound bed without slough. Stage 1 involves intact skin with non-blanchable redness. A stage 3 pressure injury involves full-thickness tissue loss and sometimes subcutaneous fat is visible. At stage 4, there is a full thickness tissue loss with exposed bone, tendon, cartilage or muscle.
Which will the nurse examine when assessing a patient for tinea corporis?
- A. Soles of the feet
- B. Scalp
- C. Groin
- D. Abdomen
Correct Answer: D
Rationale: Tinea corporis is known as ringworm of the body. It occurs on parts of the body with little or no hair. Tinea pedis is a fungal infection of the feet. Tinea capitus is a fungal infection of the scalp. Tinea cruris is a fungal infection of the groin area.
A patient has been admitted to the hospital with burns to the upper chest. The nurse notes singed nasal hairs. The nurse needs to assess this patient frequently for which condition?
- A. Decreased activity
- B. Bradycardia
- C. Respiratory complications
- D. Hypertension
Correct Answer: C
Rationale: Signs and symptoms of inhalation injury include singed nasal hairs. Breathing difficulties may take several hours to occur.