Nokea
Which question is most appropriate for the nurse to ask at this time?
- A. What childhood diseases have you had?
- B. What's your present occupation?
- C. Do you eat a well-balanced diet?
- D. How much aspirin do you take?
Correct Answer: D
Rationale: Excessive aspirin use can cause tinnitus, making it the most relevant question.
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Cimetidine [Tagamet] is ordered IV every six hours for a person with severe burns. What is the primary reason for administering Tagamet to this client?
- A. To prevent infection
- B. To restore electrolyte balance
- C. To promote renal function
- D. To prevent Curling's ulcers
Correct Answer: D
Rationale: Cimetidine is used to prevent Curling’s ulcers, stress-induced gastric ulcers common in severe burn clients due to increased gastric acid production.
The nurse is explaining facelift (rhytidectomy) surgery to the client and describing the site where the incision is most commonly made. Place an X on the site where the incision most commonly used for rhytidectomy is made.
- A. An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face.
Correct Answer: A
Rationale: An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face. Incisions in the forehead and periorbital area are for blepharoplasty and browlift. Head and neck reconstruction utilizes the chin site.
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.
Which response demonstrates that the parents understand the nurse's explanation of why organisms travel more easily from the nasopharynx to the middle ear in a child?
- A. A child's eustachian tube is shorter and straighter.
- B. A child's eustachian tube is longer and straighter.
- C. A child's eustachian tube is longer and more curved.
Correct Answer: A
Rationale: A shorter, straighter eustachian tube in children facilitates organism travel.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a dermatology clinic. Which task should not be delegated to the UAP?
- A. Stock the rooms with the equipment needed.
- B. Weigh the clients and position the clients for the examination.
- C. Discuss problems the client has experienced since the previous visit.
- D. Take the biopsy specimens to the laboratory.
Correct Answer: C
Rationale: Discussing client problems requires nursing judgment, outside UAP scope. Stocking, weighing/positioning, and transporting specimens are appropriate.