A patient has been admitted to the hospital with burns to the upper chest. The nurse notes singed nasal hairs. The nurse needs to assess this patient frequently for which condition?

Correct Answer: C

Rationale: The correct answer is C: Respiratory complications. Singed nasal hairs indicate inhalation injury, which can lead to respiratory complications such as airway swelling, pneumonia, or acute respiratory distress syndrome. Assessing the patient frequently is crucial to monitor for signs of respiratory distress and intervene promptly. Incorrect Choices: A: Decreased activity - Not directly related to singed nasal hairs or burns to the chest. B: Bradycardia - Singed nasal hairs are not typically associated with bradycardia. D: Hypertension - Singed nasal hairs do not directly indicate hypertension.

Correct Answer: A

Rationale: The correct answer is A: Cell-mediated immunity resulting in inflammatory response. Contact dermatitis is a type of dermatitis that occurs when the skin comes in contact with an irritant or allergen, leading to an inflammatory response mediated by T cells. This response causes redness, swelling, and itching at the site of contact. Choice B is incorrect because erythema and pruritus with scaling associated with phlebitis do not specifically describe contact dermatitis. Choice C is incorrect as it describes seborrheic dermatitis, not contact dermatitis. Choice D is incorrect because mast cell-stimulated release of histamine is more characteristic of allergic reactions like urticaria, not contact dermatitis.

Correct Answer: A

Rationale: The correct answer is A: "These are likely to be benign moles." The rationale is as follows: 1. Size: The nevi is less than one centimeter, which is typically indicative of a benign lesion. 2. Color: The description of a flat brown circular nevi suggests a classic appearance of a benign mole. 3. Assessment: Based on the characteristics provided, the nurse can reasonably assume that the nevi are benign. In summary, the other choices are incorrect because B is too alarmist without proper assessment, C is an extreme statement without sufficient evidence, and D is incorrect as verrucae are wart-like growths, not moles.

Correct Answer: A

Rationale: The correct answer is A: assessing peripheral pulses. In circumferential burns of both legs, there is a risk of compartment syndrome due to swelling and restricted blood flow. Assessing peripheral pulses helps determine if there is adequate circulation to the extremities, which is crucial for preventing tissue damage and ensuring limb viability. It is the priority because impaired circulation can lead to serious complications like tissue necrosis. Assessing neurological status (B) is important but assessing circulation takes precedence. Assessing urine output (C) and blood pressure (D) are essential but not as immediate in this scenario.

Correct Answer: D

Rationale: The correct answer is D: press firmly on the lesion. By pressing firmly on the lesion, the nurse can assess if the redness blanches, indicating that it is related to blood vessel dilation. Palpating pulses (choice A) would not provide information on blood vessel dilation. Checking skin temperature (choice B) may not directly indicate blood vessel dilation. Elevating the leg (choice C) may help with circulation but does not directly assess blood vessel dilation. Pressing on the lesion (choice D) is the best choice as it can help determine if the redness is due to blood vessel dilation.