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Which nursing intervention is most appropriate to add to the care plan to reduce the client's anxiety?
- A. Let the client suggest ways to carry out care.
- B. Discontinue nursing care measures at this time.
- C. Restrict care to nutrition and elimination only.
- D. Carry out nursing activities quickly and efficiently.
Correct Answer: A
Rationale: Involving the client in care decisions reduces anxiety by providing control.
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When describing the examination procedure to the client, which statement by the nurse is most accurate?
- A. You'll read words that are the size of newsprint.
- B. You'll read letters from a distance of 20 feet to mears.
- C. You'll look at a color picture and identify an image.
- D. You'll look at a screen and tell me when an object appears.
Correct Answer: B
Rationale: The Snellen chart involves reading letters from 20 feet to assess visual acuity.
The nurse correctly teaches the client that psoriasis is an inflammatory dermatosis that results from which skin condition?
- A. A superficial skin infection
- B. The effects of dermal abrasion
- C. A proliferation of epidermal cells
- D. An infection of the hair follicles
Correct Answer: C
Rationale: Psoriasis involves rapid epidermal cell turnover.
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.
The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document?
- A. Superficial partial thickness.
- B. Deep partial thickness.
- C. Full thickness.
- D. First degree.
Correct Answer: B
Rationale: Blistered, mottled red skin with edema indicates deep partial-thickness burns, affecting the dermis with severe pain. Superficial partial thickness has no blisters, full thickness is painless and leathery, and first degree is superficial with erythema.
The nurse is caring for the client with problems of anxiety and confusion in the critical phase of burn injury. Which interventions should the nurse implement? Select all that apply.
- A. Repeat orientation statements of person, place, and time.
- B. Turn and reposition the client at least every 2 hours.
- C. Place familiar objects from home near the client.
- D. Implement a schedule for regular sleep-wake cycles.
- E. Control distractions by keeping the room door closed.
- F. Encourage the client to write notes to family members.
Correct Answer: A,C,D
Rationale: Reiterating statements of orientation to the client decreases confusion. Familiar objects reduce anxiety when clients are in unfamiliar surroundings. Employing a regular schedule for sleep-wake cycles assists in decreasing confusion and anxiety. Turning and repositioning improves circulation and aeration but does not affect confusion. Closing the door of the room may increase client anxiety. In the acute phase of burns, the client is too ill to write notes to family members.