A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, the fingers are mottled, and the radial pulse is now absent. The client states that the pain is 8/10. What is the priority action the nurse should take?

Instruct the client to exercise the fingers and wrist.

Call the healthcare provider to report the loss of the radial pulse.

Continue to assess the arm every hour for any additional changes.

Administer morphine IV.

Answer and Explanation

The Correct Answer is B

Choice A reason: Instructing the client to exercise the fingers and wrist is not the immediate priority. While maintaining mobility is important in burn care, the absence of a radial pulse indicates a potential vascular compromise that needs urgent attention.

Choice B reason: Calling the healthcare provider to report the loss of the radial pulse is the correct and immediate action. The absence of a radial pulse suggests that the edema is causing compartment syndrome, which can lead to tissue ischemia and necrosis if not promptly treated. This is a medical emergency requiring immediate intervention, possibly including a fasciotomy to relieve pressure.

Choice C reason: Continuing to assess the arm every hour for additional changes is important, but it is not the immediate priority. The absence of a radial pulse indicates a critical issue that needs immediate reporting and intervention, rather than waiting for further changes.

Choice D reason: Administering morphine IV can help manage the client's pain, which is significant at 8/10. However, it does not address the underlying issue of the absent radial pulse and potential compartment syndrome. Pain management is important but secondary to resolving the vascular compromise.

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Correct Answer is D

Explanation

Choice A reason: Administering a muscle relaxant addresses the symptom of muscle twitching and jerking, but it does not identify or treat the underlying cause. For patients with acute pancreatitis, muscle twitching and jerking could be indicative of a more serious condition.

Choice B reason: While a nutritional imbalance could potentially lead to symptoms like muscle twitching and jerking, in the context of acute pancreatitis, the nurse should consider more specific causes related to the condition. Nutritional imbalances do not usually explain these symptoms in patients with pancreatitis as well as hypocalcemia does.

Choice C reason: A reaction to morphine could include various symptoms such as itching, nausea, or constipation, but muscle twitching and jerking are not common side effects. The nurse should consider other causes related to the patient's condition of acute pancreatitis.

Choice D reason: Hypocalcemia, or low calcium levels, is a common complication of acute pancreatitis. It can lead to symptoms such as muscle twitching and jerking, as calcium is crucial for proper muscle function and nerve signaling. This makes hypocalcemia the most relevant and accurate interpretation of the patient's symptoms in this context.

A. Age B. Hypertension C. Obesity D. Smoking E. Stress

Correct Answer is ["B","C","D","E"]

Explanation

Choice A reason: Age is a non-modifiable risk factor for coronary artery disease. While it is a significant risk factor, individuals cannot change their age. Modifiable risk factors are those that individuals can alter through lifestyle changes or medical interventions to reduce their risk of developing coronary artery disease.

Choice B reason: Hypertension, or high blood pressure, is a modifiable risk factor for coronary artery disease. By managing blood pressure through lifestyle changes, medications, and regular monitoring, individuals can reduce their risk of developing coronary artery disease. Effective management of hypertension includes reducing sodium intake, maintaining a healthy weight, exercising regularly, and taking prescribed medications.

Choice C reason: Obesity is a modifiable risk factor for coronary artery disease. Individuals can work towards achieving and maintaining a healthy weight through dietary changes, increased physical activity, and behavioral modifications. Losing weight can significantly lower the risk of coronary artery disease by improving blood pressure, cholesterol levels, and overall cardiovascular health.

Choice D reason: Smoking is a major modifiable risk factor for coronary artery disease. Quitting smoking can dramatically reduce the risk of developing coronary artery disease and other cardiovascular conditions. Smoking cessation programs, medications, and support groups can help individuals successfully quit smoking and improve their cardiovascular health.

Choice E reason: Stress is a modifiable risk factor for coronary artery disease. Chronic stress can contribute to the development of coronary artery disease by affecting blood pressure, cholesterol levels, and overall heart health. Managing stress through relaxation techniques, exercise, counseling, and mindfulness practices can help reduce the risk of coronary artery disease.

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A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, the fingers are mottled, and the radial pulse is now absent. The client states that the pain is 8/10. What is the priority action the nurse should take?

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Naxlex Comprehensive Predictor Exams

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the relevance of these symptoms?

Correct Answer is D

Explanation

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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