A client admitted to the emergency department (ED) with burns of the chest and neck exhibits a wet, shiny, weeping surface with some blistering. The nurse would document these burn injuries as
a. full thickness, fourth degree.
b. full thickness, third degree.
c. partial thickness, second degree.
d. superficial, first degree.
C
Second-degree partial-thickness burns appear wet or blistered and are extremely painful but can heal without intervention (i.e., skin grafting) if they are small and do not become infected. A superficial, first-degree burn is red and painful, and looks like a sunburn. Full-thickness third-degree burns appear dry; perhaps mottled; and black, brown, white, or red in color. It is usually painless directly on the burn. The full-thickness fourth-degree burn appears charred and the burned part may be completely burned away.
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A patient is brought to the ED by two police officers
The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained? A) Frequently assess the patient's skin integrity. B) Inform the patient that he is likely to be charged with assault. C) Avoid interacting with the patient until the restraints are removed. D) Take the opportunity to perform a full physical assessment.
The nursing student is assigned to care for a patient who has just been diagnosed with advanced stage cancer. The patient is very upset and crying. The nursing student states to her instructor, "I don't know what to do
My patient just can't stop crying." What is the best response from the instructor? a. "Sometimes just sitting with patient and remaining silent can be the best care." b. "You will need to wait patiently until your patient stops crying to complete your care." c. "You will not be effective while he is crying. Tell the patient you will come back later." d. "Try to distract the patient from crying by trying to change the conversation."
A patient is taking an opiod analgesic for acute pain rated 9/10 after abdominal surgery. Which adverse effect would the nurse need to respond to most rapidly?
a. Patient complaint of constipation. b. Increased urination to 60 mL per hour. c. Heart rate elevation to 90 beats per minute. d. Respiratory rate reduced to 8 breaths per minute.
A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The nurse records this as how many pack-years?
a. 10 b. 20 c. 40 d. 60