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Questions 157

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Extract:


Question 1 of 5

The client has sustained severe burns on both the anterior right and left leg and the anterior chest and abdomen. According to the rule of nines, what percentage of the body has been burned?

Correct Answer: 36

Rationale: Rule of nines: anterior legs (9% each = 18%), anterior chest/abdomen (18%) = 18% + 18% = 36%.

Question 2 of 5

Which assessment data indicate the treatment for the client diagnosed with bacterial meningitis is effective?

Correct Answer: D

Rationale: Neck flexibility without pain indicates reduced meningeal inflammation, a sign of effective meningitis treatment.

Question 3 of 5

According to the nursing process, which interventions should the nurse implement when caring for a client diagnosed with a right-sided cerebrovascular accident (stroke) and who has difficulty swallowing? List the interventions in order of the nursing process.

Order the Items

Source Container

Write the client problem of 'altered tissue perfusion.'
Assess the client's level of consciousness and speech.
Request dietary to send a full liquid tray with Thick-It.
Instruct the UAP to elevate the head of the bed 30 degrees.
Note the amount of food consumed on the dinner tray.

Correct Answer: B,A,C,D,E

Rationale: 1) Assess LOC/speech (assessment); 2) Write problem (diagnosis); 3) Request diet (planning); 4) Instruct HOB elevation (implementation); 5) Note food intake (evaluation).

Question 4 of 5

Which information would be most important for the public health department nurse to obtain before giving the client condoms?

Correct Answer: C

Rationale: Latex allergies can cause severe reactions, making it critical to assess before providing condoms. Frequency, preferences, and history are secondary.

Question 5 of 5

The client diagnosed with neurogenic diabetes insipidus (DI) asks the nurse, 'What is wrong with me? Why do I urinate so much?' Which statement by the nurse is most appropriate?

Correct Answer: B

Rationale: Neurogenic DI results from ADH deficiency due to pituitary dysfunction, causing polyuria.

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