Following establishment of an airway, adequate breathing, and circulation, the nurse would focus next on which assessment following a burn injury?
1. Determining total body surface area of the burn
2. A quick check of neurologic status
3. Psychologic trauma resulting from the incident
4. Details of how the injury occurred
2
Rationale 1: The TBSA percentage and details of how the burn occurred would also be important assessments but are done after the ABCs are completed.
Rationale 2: Once the initial ABCs have been assessed, neurologic status should be examined. A burn patient should be awake and able to follow commands. Decreased neurologic status or unconsciousness may indicate anoxic injury or an additional neurologic injury.
Rationale 3: Physical needs and assessments must be completed prior to psychologic needs.
Rationale 4: This would be done after the airway has been secured.
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a. Subacromial bursa. b. Acromion process. c. Glenohumeral joint. d. Greater tubercle of the humerus.
The nurse is helping an older patient with a history of angina ambulate in the hallway after minor surgery. The patient complains of chest tightness. What should the nurse do first?
a. administer nitroglycerin sublingually b. call for help c. have the patient sit and rest d. take the vital signs
Long-term use of dopaminergic drugs often leads to:
1. muscle flaccidity. 2. migraine headaches. 3. incontinence. 4. tardive dyskinesia.
Girls experience an increase in weight and fat deposition during puberty. What do nursing considerations related to this include?
a. Give reassurance that these changes are normal. b. Suggest dietary measures to control weight gain. c. Encourage a low-fat diet to prevent fat deposition. d. Recommend increased exercise to control weight gain.