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Questions 158

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Question 1 of 5

A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn?

Correct Answer: D

Rationale: (A, B,
C) These answers are all correct; however, maintenance of airway is the top priority. Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest.

Question 2 of 5

A 25-year-old lawyer who is married with three young children works long hours in an effort to become a partner in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed him or her that he was a busy man and did not have much time for this 'psych stuff.' When guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:

Correct Answer: D

Rationale: Repressed anger is associated with psychophysiological disorders like a bleeding ulcer, as stress and unexpressed emotions contribute to physical symptoms.

Question 3 of 5

A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:

Correct Answer: D

Rationale: Inserting a finger into the infant's mouth breaks suction, allowing nipple removal without trauma. Other methods risk nipple injury.

Question 4 of 5

The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?

Correct Answer: A

Rationale: Verifying nasogastric tube placement by aspirating stomach contents (and checking pH) is critical to prevent aspiration. Left-lying position is incorrect, 50% dextrose is inappropriate, and microwaving can cause burns or nutrient degradation.

Question 5 of 5

The nurse is assessing a client with suspected tuberculosis. Which precaution should be implemented?

Correct Answer: B

Rationale: Tuberculosis is transmitted via airborne droplets, requiring airborne precautions (e.g., N95 mask, negative pressure room). Standard, droplet, and contact precautions are insufficient.

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