Local tissue injury response from burns becomes systemic when more than what percentage of the body is involved?
a. 5 c. 15
b. 10 d. 20
D
Local tissue injury response from burns becomes systemic when more than 20 percent of the body is involved. These clients have an increased susceptibility to multiple organ failure and sepsis.
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A patient is diagnosed with damage to the spinothalamic tract of the spinal cord. Which assessment finding would the nurse attribute to this damage?
1. The patient reports an unusual amount of pain. 2. Muscle spasms are occurring in the patient's right leg. 3. The patient has ataxia. 4. The patient is complaining of vertigo.
The nurse understands that the following organization believes that cultural competence in nursing is necessary?
a. Nurse Practice Acts of state boards of nursing b. Code of Ethics of the American Nurses Association c. Accreditation standards of the National League of Nursing d. Accreditation standards of The Joint Commission (TJC)
A 45-year-old woman asks the nurse why she has her height measured at each annual checkup. What is the most appropriate response?
a. "Loss of height can be an early indication of bone loss due to osteoporosis." b. "Measuring your height annually allows us to most accurately calculate your body mass." c. "Insurance companies require the measurement of height for reimbursement." d. "Loss of height can be an early indication of protein deficiency."
The correct procedure for eye irrigation is to:
A. Hold the irrigating device approximately 1 inch from the eye, ask the client to look toward the brow, and gently irrigate from the inner toward the outer canthus B. Steady the irrigating device on the eye surface and irrigate briskly from the center of the eye outward C. Hold the irrigating device 6 inches from the eye, ask the client to look toward the nose, and irrigate from the outer to the inner canthus D. Select the procedure based on the condition of the client and the reason for the irrigation