A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care?

Correct Answer: A

Rationale: In this scenario, the most important intervention for the nurse to include in the client's plan of care is continuous cardiac monitoring (option A). Electrical injuries can cause cardiac arrhythmias and monitoring the client's heart rhythm is crucial to detect any abnormalities early on. Option B, performing passive range of motion, is not the priority in this situation as cardiac monitoring takes precedence due to the potential life-threatening complications of electrical injuries on the heart. Option C, evaluating the level of consciousness, is important but not as critical as continuous cardiac monitoring in this context. Changes in consciousness can be secondary to cardiac issues and would be detected through cardiac monitoring. Option D, assessing lung sounds q4 hours, is also important but not as urgent as continuous cardiac monitoring. While respiratory complications can occur in burn patients, cardiac monitoring is a higher priority in this case. Educationally, this question highlights the importance of recognizing the potential complications of electrical injuries, prioritizing interventions based on the client's condition, and understanding the critical role of continuous cardiac monitoring in such cases.

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to take is option D: Instruct the client in pursed lip breathing techniques. This is the most appropriate intervention for a patient with COPD experiencing shortness of breath. Pursed lip breathing can help improve gas exchange and decrease the work of breathing in COPD patients. By teaching the client this technique, the nurse empowers the individual to better manage their respiratory distress. Option A is incorrect because simply moving the client to a high Fowler's position may not address the underlying issue of ineffective breathing. Option B, observing for a barrel chest, is not the priority intervention in this acute situation. Option C, preparing to transfer to a critical care unit, is premature without first implementing non-invasive interventions like pursed lip breathing techniques. Educationally, understanding the rationale behind interventions in respiratory conditions like COPD is crucial for nurses caring for these patients. Teaching patients effective breathing techniques empowers them in self-management and can improve outcomes and quality of life. Nurses must be adept at recognizing respiratory distress and implementing appropriate interventions promptly.

Correct Answer: A

Rationale: In this scenario, the most important action for the nurse to implement is option A, using a doppler to assess bilateral pedal pulses. This is crucial in determining the vascular status of the affected leg, especially in a situation where a client presents with an externally rotated and shortened leg, severe pain, tingling, and absent pedal pulses. Without proper circulation, there is a risk of ischemia and potential long-term complications. Option B, administering pain medication, is not the most critical action at this stage. While managing pain is important, assessing vascular status takes precedence to ensure adequate blood flow to the affected limb. Option C, positioning the client's left leg in a neutral position, may offer some comfort but does not address the urgent need to assess circulation. Delaying vascular assessment can lead to further complications. Option D, immobilizing the left leg, is not appropriate without first assessing the vascular status. Immobilization may be necessary later for treatment but should not delay immediate assessment and intervention for vascular compromise. In an educational context, this scenario highlights the importance of prompt and systematic assessment in nursing practice, especially in emergencies involving potential vascular compromise. Nurses must prioritize actions based on the client's condition to provide safe and effective care. Understanding the rationale behind each option helps nurses develop critical thinking skills to make sound clinical judgments in similar situations.

Correct Answer: A

Rationale: The correct answer is A) Do you see any improvement when using tolnaftate? This question is pertinent because tinea pedis is a fungal infection of the feet, commonly known as athlete's foot, and tolnaftate is an antifungal medication used to treat this condition. By asking about improvement with tolnaftate, the nurse can assess the effectiveness of the treatment and the client's adherence to it. Option B) Have you been avoiding wearing tight-fitting shoes? While wearing loose-fitting shoes can help prevent tinea pedis, this question does not directly address the current status or treatment of the condition. Option C) Are you experiencing pain or itching in your feet? While pain and itching are common symptoms of tinea pedis, this question does not specifically address the treatment or improvement of the condition. Option D) How often do you wash your feet and change socks? While proper hygiene practices can help prevent tinea pedis, this question does not address the specific treatment or improvement with tolnaftate. In an educational context, understanding the rationale behind the correct question allows nurses to assess the effectiveness of treatment interventions, monitor client response to therapy, and make informed decisions regarding ongoing care for clients with tinea pedis. This approach enhances the nurse's ability to provide individualized, evidence-based care and promote positive health outcomes for pediatric clients with cardiovascular conditions.

Correct Answer: D

Rationale: In this scenario, the correct response is option D: Demonstrate the use of visual scanning during meals to the client and family. This is the most appropriate action because the client's difficulty with visual perception may be impacting her ability to see and recognize food on her plate, leading to decreased intake. By teaching the client and family how to use visual scanning techniques during meals, the nurse can help improve the client's ability to identify and consume food effectively. Option A: Encouraging the family to feed the client may undermine the client's independence and dignity. It is important to empower the client to feed themselves with appropriate assistance as needed. Option B: Suggesting that the family bring foods from home that the client enjoys does not address the underlying issue of visual perception difficulties. It is essential to address the root cause of the client's decreased food intake rather than simply offering different food options. Option C: Explaining that weight loss will be reversed after the acute phase of the stroke has ended does not provide immediate support or intervention for the client's current nutritional concerns. It is crucial to address the client's nutritional needs in the present moment to prevent further complications and promote recovery. In an educational context, understanding how to assess and address nutritional concerns in patients with neurological deficits, such as those following a CVA, is vital for pediatric cardiovascular nurses. Teaching effective strategies like visual scanning can significantly impact a patient's ability to maintain adequate nutrition and support their overall recovery and well-being.