The client recovering from full- and partial-thickness burns asks the nurse why some areas hurt more than others. The nurse's best response would include which of the following?
1. "There usually is not that much pain associated with burns, so the areas that hurt are those that might be infected."
2. "Deeper burns release more endorphins because of increased tissue damage, which lessens pain."
3. "Deeper full-thickness burns damage nerve pathways, which interrupt the pain message from reaching the brain."
4. "Deeper partial thickness burns damage nerve pathways, which interrupt the pain message from reaching the brain."
3
Rationale: Pain is the response to tissue damage that sends a message to the brain via the spinal column. With full-thickness burns, the nerve pathways are damaged, so the pain message is never sent to the brain. While the nurse would not tell the client this information, as the nerves begin to regenerate, the pain messages will get through to the brain, and pain will increase with recovery. Burns are very painful, and there is no indication this client has an infection.
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The nurse is making a home visit to a client who had a cesarean birth 3 days ago. Assessment reveals that the client is complaining of intermittent pain, rating it as 8 on a scale of 1 to 10
She states, "I'm pretty tired. And with this pain, I haven't been drinking and eating like I should. The medication helps a bit but not much. My mom has been helping with the baby." Her incision is clean, dry, and intact. Which nursing diagnosis would the nurse identify as the priority for this client? A) Impaired skin integrity related to cesarean birth incision B) Fatigue related to effects of surgery and caretaking activities C) Imbalanced nutrition less than body requirements related to poor fluid and food intake D) Acute pain related to incision and cesarean birth
Which simulator model is most appropriate for learning to obtain an arterial blood gas?
a. Standardized patient b. Computer-controlled mannequin c. Arm model from elbow to fingers d. Computer model
The nurse should observe a client with bacterial meningitis for
a. changes in sensorium. b. high blood pressure. c. hypothermia. d. muscle spasms.
The following progressive leadership tracks are promoted by the American Nurses Association Leadership Institute EXCEPT
A. Preparing B. Emerging C. Developing D. Advanced