A client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding is present, and the client describes just a "small amount of pain." How does the nurse categorize this injury?
a. Partial thickness deep
b. Partial thickness superficial
c. Full thickness
d. Superficial
C
The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Par-tial-thickness superficial burns appear pink to red and are painful. Partial-thickness burns are deep red to white and painful, and superficial burns are pink to red and are also painful.
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Risk factors predisposing a person to respiratory depression with the use of opioid analgesics include all of the following EXCEPT
a. renal dysfunction c. altered level of con-sciousness b. normal liver function d. abdominal distention
Five-year-old William is present in the room when his father passes away. He is aware that his mother and grandparents are crying, but he tells them not to worry. "This happens all the time on my cartoon show. Come on, Daddy; wake up now
" Nurses understand that children also experience the stages of grief. As the nurse caring for this family, you know that at William's age it is important to: A) Divert William's attention away from his father by asking about his favorite cartoon show B) Tell William that this is not his fault and he did nothing to cause his father's death C) Ask another relative to take William home D) Reassure William that his mother will explain the situation to him later
The nurse suspects a client is experiencing left-sided heart failure when which of the following is assessed? (Select all that apply.)
1. Decreased basilar lung sounds 2. Distended neck veins 3. Extra heart sounds 4. Lung crackles 5. Tachycardia 6. Weight gain
The nurse is attempting to ambulate an older adult client who recently experienced a fall at the assisted living facility where he resides
The client is reluctant to walk and consents to move only to the chair, reporting that "it hurts too much to walk." Which of the following nursing interventions is most therapeutic regarding this client? 1. Allow the client to remain in bed in order to conserve his energy. 2. Transfer him to the chair, realizing some activity is preferable to none. 3. Call his health care provider to discuss the apparent ineffectiveness of his pain medications. 4. Assess the client for other factors that may be affecting his ability and motivation to ambulate.