A patient comes into the emergency department with severe burns over the face, arms, legs, and back after spending the day boating with friends. The skin is dry and very red with brisk capillary refill. How would the nurse classify this patient's burn injuries?
1. Superficial
2. Deep partial thickness
3. Superficial partial thickness
4. Full thickness
Answer: 1
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A family caregiver is learning to administer insulin injections to her homebound sister. What should the nurse advise her to do with the used needles?
1) Discard the needle and syringe in a thick plastic milk jug with a lid. 2) Securely recap them and place them a paper bag in the household trash. 3) Remove the needle and put it in a coffee can with a lid; put the syringe in the trash. 4) Do not recap the needle; break it by bending it on the table top.
When checking the patient's back, the nurse pushes her thumb into the patient's sacrum. An indentation remains. The nurse charts that the patient has
a. sacral compromise. b. delayed skin turgor. c. pitting edema. d. dehydration.
Assessment of a pt with a lower spinal cord injury confirms that the pt has paralysis of the bilateral lower extremities. How does the nurse document this finding?
a. paraparesis b. paraplegia c. quadriparesis d. quadriplegia
You state, "Tell me what's going on with you right now. Maybe I can help you be more
comfortable." What would be the benefit of taking this approach? What will be an ideal response?