The nurse examines the client admitted for burns to the right hand and notes redness and a blister over the palm of the hand. The client reports it is painful but that some areas have reduced sensation. The nurse classifies this burn as:
1. Superficial.
2. Superficial partial-thickness.
3. Deep partial-thickness.
4. Full-thickness.
3
Rationale: The blister and reduced sensation in some areas indicate the burn is a deep partial-thickness burn. A superficial burn can be red, a superficial partial-thickness burn would not blister, and a full-thickness burn would be black, charred, and leathery, and the client would have no pain, because nerve endings would have been damaged.
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Which of the following should the nurse use to assess a nonverbal older adult for delirium?
a. Cranial nerves XI and XII b. Confusion Assessment Method c. MMSE-2 d. Controlled Word Association Test
The nurse teaches the patient at risk for coronary artery disease (CAD) that some risk factors can be controlled or modified. What modifiable factors would the nurse include?
A) Gender, obesity, family history, and smoking B) Inactivity, stress, gender, and smoking C) Obesity, inactivity, diet, and smoking D) Stress, family history, and obesity
A nurse is reviewing research articles in an effort to make changes in practice in a medical-surgical unit. To evaluate the quality of the research performed, which source should be recommended?
1. U.S. Preventive Services Task Force (USPSTF) 2. The National Guideline Clearinghouse (NGC) 3. National Quality Forum (NQF) 4. The Agency for Healthcare Research and Quality (AHRQ)