Extract:

Question 1 of 5

How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

A. Laterally on the left side with a pillow under the head and the right arm and hand hyperextendedB. Supine with a pillow under the head, and elevate the right hand and arm on a pillowC. Semi-Fowler's position without a pillow under the head, and the right arm and hand elevated on a pillowD. Prone without a pillow, and with the right arm and hand flexed in a position of comfort and elevated on a pillow

Correct Answer: C

Rationale: Semi-Fowler's position without a pillow and elevating the arm prevents contractures and promotes edema drainage.

Question 2 of 5

The nurse is caring for a client, with no other pertinent medical history, who was burned over 70% Total Body Surface Area (TBSA) and weighs 70kg. Using the Parkland Formula, calculate the amount of intravenous fluid required in the first 8 hours after the burn.

Correct Answer: B

Rationale: Using the Parkland Formula:
Total fluid requirement = 4 Ã— 70 kg Ã— 70% TBSA = 19,600 mL (total for 24 hours). Fluids in first 8 hours = 19,600 mL Ã· 2 = 9,800 mL.

Question 3 of 5

The nurse is assessing a client for Brudzinski's sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? (SELECT ALL THAT APPLY)

A. Bend the client's head toward their chestB. Ask the client to extend both arms above their headC. Place the client in supine positionD. The nurse will place a hand behind the client's headE. Assist the client to bend their knee 90 degrees

Correct Answer: A,C,D

Rationale: Flexing the neck in a supine position with a hand behind the head tests for Brudzinski's sign.

Question 4 of 5

A client receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter inserted. When evaluating the client's intake and output, which of the following should be taken into consideration? The amount of urine:

A. is expected to be decreased for three to five days.B. will be reduced in the first 24-48 hours and will then increase.C. output will be greatest in the first 24 hours after the burn injury.D. will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.

Correct Answer: B

Rationale: In the first 24-48 hours following a severe burn injury, the body may undergo a state of hypovolemia and oliguria. As fluid resuscitation begins, urine output typically increases.

Question 5 of 5

Complete the following sentence with one of the options regarding the pathophysiology of this type of shock. The nurse isp caring for an elderly patient from a nursing home diagnosed with a urinary tract infection. The nurse assesses the patient as hypotensive, tachycardic, febrile, tachypneic, and with an altered mental status. The nurse understands that the pathophysiology of this type of shock is caused by___

A. Massive blood loss leading to decreased oxygen delivery to tissuesB. Severe allergic reaction causing systemic vasodilation and increased capillary permeabilityC. Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusionD. Cardiac failure resulting in inadequate tissue perfusion and oxygenation

Correct Answer: C

Rationale: The patient is exhibiting signs of septic shock, which occurs as a result of a severe infection leading to systemic inflammatory response syndrome (SIRS). The presence of fever, tachycardia, tachypnea, hypotension, and altered mental status strongly suggests sepsis progressing to septic shock.