A client has a circumferential third-degree burn on the upper left arm. The nursing assessments specific for this client would include
a. assessing capillary refill in the left hand.
b. evaluating left hand strength.
c. measuring left forearm circumference.
d. monitoring blood pressure in the left arm.
A
Circulatory compromise may occur in the case of a circumferential burn. Therefore frequent assessment of distal extremity perfusion is necessary. Since it is circulation that may be compromised, tests of muscle strength are not specifically needed. Measuring circumference is not a routine assessment and blood pressure would need to be taken in the other arm.
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A nurse in the ICU is extremely efficient in performing her tasks but often realizes at the end of the day that she has not taken the time to make eye contact with her patients. Which element of practice excellence is this nurse lacking?
A) Action B) Balance C) Mastery D) Vision
During a preoperative assessment, the nurse learns that a client takes all-natural nutritional supplements. Which response should the nurse make to this client?
a. "Discuss this with the anesthesiologist the day of surgery." b. "Skip the supplements the day of surgery, but resume afterwards." c. "Since the dietary supplements are "all natural" there should not be a problem." d. "Even all-natural dietary supplements may interact with anesthesia, medications, or alter blood clotting."
After teaching a group of nursing students about the impact of pregnancy on the older woman, the instructor determines that the teaching was successful when the students state which of the following?
A) "The majority of women who become pregnant over age 35 experience complications.". B) "Women over the age of 35 who become pregnant require a specialized type of assessment.". C) "Women over age 35 and are pregnant have an increased risk for spontaneous abortions.". D) "Women over age 35 are more likely to have substance abuse problems.".
A nurse is explaining how the relapse cycle works to a group of hospitalized clients who have co-occurring disorders involving cognitive disorders and alcoholism. Which of the following statements should the nurse use in her explanation?
A) "Once you are discharged, there is a tendency to use alcohol rather than your prescribed medications to self-medicate your psychiatric symptoms. This allows your psychiatric symptoms to surface once again, and they, in turn, lead to re-hospitalization. Your symptoms are again controlled with medications until you are discharged and the cycle starts all over again." B) "Your alcoholism causes you to hallucinate, and you need to take prescribed medications to control the hallucinations. Once you try to stop drinking and stay abstinent, your hallucinations disappear; consequently, you stop taking your prescribed medications because they're gone. Then, you celebrate with alcohol, and this triggers a relapse; the alcoholism causes hallucinations and the whole thing starts over again." C) "Your dependence on alcohol and your psychiatric illness are unrelated. Being psychotic does not cause alcoholism, and alcoholism does not cause psychosis. It all boils down to medication compliance." D) "The cycle is triggered by repeated attempts to stop drinking. Without the levels of alcohol your system has come to tolerate, you begin to develop psychiatric symptoms. Then you have to be hospitalized and treated for your psychosis once again. Everything is fine until the next time you try to stop drinking, and then the cycle repeats itself."