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| Section | Weight | Objectives |
|---|---|---|
| Safe and Effective Care Environment | 17–33% | - Management of Care - Safety and Infection Control |
| Physiological Integrity | 43–67% | - Physiological Adaptation - Basic Care and Comfort - Pharmacological and Parenteral Therapies - Reduction of Risk Potential |
| Psychosocial Integrity | 6–12% | |
| Health Promotion and Maintenance | 6–12% |
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NEW QUESTION # 699
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48-72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
NEW QUESTION # 700
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
NEW QUESTION # 701
A client's physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client's COPD. Instructions that should be given to the client include:
Answer: C
Explanation:
Explanation
(A) Indications of theophylline toxicity include palpitations, dizziness, restlessness, nausea, vomiting, shakiness, and anorexia. (B) Cigarette smoking significantly lowers theophylline plasma levels. (C) Theophylline should be taken with food to decrease stomach upset. (D) These instructions are appropriate for someone taking digoxin.
NEW QUESTION # 702
A client is being admitted to the labor and delivery unit. She has had previous admissions for "false labor." Which clinical manifestation would be most indicative of true labor?
Answer: A
Explanation:
(A) Bloody show is considered a sign of imminent labor, which usually begins in 24-48 hours. An increase in bloody show is an indication that the cervix is changing. (B) Contractions of true labor produce progressive cervical effacement and dilatation. (C) Contractions of false labor may mimic those of true labor. However, the contractions of false labor do not produce progressive effacement and dilatation of the cervix. (D) In true labor, the discomfort is not relieved by ambulation; walking may intensify the discomfort.
NEW QUESTION # 703
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?
Answer: B
Explanation:
Explanation
(A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals.
NEW QUESTION # 704
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