An adult has a thermal burn injury involving all of one leg and the entire posterior trunk. There are also three scattered areas on the anterior trunk, each approximately the size of the patient's palm
As part of initial assessment, the nurse calculates the size of the burn using a combination of the Rule of Nines and the Rule of Palm. What is the result of this calculation in percentage of total body surface area (TBSA)?
39%
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The nurse is assessing a patient with pain in the lower back. Which questions or results indicate the nurse is using divergent thinking during the assessment process?
Select all that apply. 1. "Tell me about your dietary practices." 2. "Can you tell me on a scale of 1 to 10, with 10 being the worst, how you would rate your pain now?" 3. The nurse notes a cluster of blisters on the patient's scapula. 4. "When was the last time you had a physical?" 5. "Does your eyesight affect your ability to see the insulin you are taking?"
The nurse is presenting a class for nursing students on multiple-gestation pregnancy. Which statements about multiple-gestation pregnancies are accurate? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Hypertension is a major maternal complication. 2. Gestational diabetes occurs more often. 3. Maternal anemia occurs. 4. Pulmonary embolism is 12 times more likely to develop during pregnancy with multiple gestations. 5. Multiple gestations are more likely to acquire HELLP.
The nurse is caring for a patient in the sleep lab. The nurse recognizes that the patient is in stage 4 NREM from which of the following assessments?
a. The patient awakens easily. b. Body functions slow. c. The patient is difficult to awaken. d. Eyes rapidly move.
A patient received atropine intravenously before surgery
The recovery room nurse notes that the patient is delirious upon awakening, has a heart rate of 96 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 110/78 mm Hg. The nurse notifies the anesthesiologist, who will order: a. activated charcoal to minimize intestinal absorption of the antimuscarinic agent. b. an acetylcholinesterase inhibitor to compete with the antimuscarinic agent at receptors. c. an antipsychotic medication to treat the patient's central nervous system symptoms. d. ipratropium bromide (Atrovent) to counter the respiratory effects of the antimuscarinic agent.