A client receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter inserted. When evaluating the client's intake and output, which of the following should be taken into consideration? The amount of urine:

is expected to be decreased for three to five days.

will be reduced in the first 24-48 hours and will then increase.

output will be greatest in the first 24 hours after the burn injury.

will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.

Answer and Explanation

The Correct Answer is B

A. is expected to be decreased for three to five days.
In the initial stages following severe burn injury, there is often oliguria (low urine output), but this is typically followed by diuresis (increased urine output) after the first 24-48 hours, not a decrease over 3-5 days.

B. will be reduced in the first 24-48 hours and will then increase.
In the first 24-48 hours following a severe burn injury, the body may undergo a state of hypovolemia and oliguria. As fluid resuscitation begins, urine output typically increases.

C. output will be greatest in the first 24 hours after the burn injury.
Although urine output may increase with proper fluid resuscitation, it is not usually greatest in the first 24 hours; the increase typically happens after the initial resuscitation period.

D. will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
While fluid resuscitation leads to an increase in urine output after the first 24-48 hours, it is not expected to be elevated right away. The kidneys may initially respond with oliguria.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Inability to understand directions
The client's issue is with motor coordination, not comprehension.

B. Lesion of cranial nerve IX
Cranial nerve IX (Glossopharyngeal) is associated with swallowing and taste, not motor coordination.

C. Dysfunction of the cerebellum
The cerebellum controls coordination and fine motor movements. The client's inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.

D. Vestibular disease
Vestibular disorders cause dizziness, vertigo, and balance problems but do not typically affect rapid alternating movements.

A. Bend the client's head toward their chest B. Ask the client to extend both arms above their head C. Place the client in supine position D. The nurse will place a hand behind the client's head E. Assist the client to bend their knee 90 degrees

Correct Answer is ["A","C","D"]

Explanation

A. Bend the client’s head toward their chest is correct because Brudzinski’s sign is tested by flexing the client’s neck and observing for an involuntary flexion of the hips and knees, which suggests meningeal irritation.

B. Ask the client to extend both arms above their head is incorrect; this is not part of the test for Brudzinski’s sign.

C. Place the client in a supine position is correct because the test must be done with the client lying flat on their back.

D. The nurse will place a hand behind the client’s head is correct because the nurse gently lifts the client’s head to assess for involuntary hip and knee flexion.

E. Assist the client to bend their knee 90 degrees is incorrect; knee bending is not required for Brudzinski’s sign but is part of Kernig’s sign testing.

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A client receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter inserted. When evaluating the client's intake and output, which of the following should be taken into consideration? The amount of urine:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is assessing a client for Brudzinskis sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? SELECT ALL THAT APPLY

Correct Answer is ["A","C","D"]

Explanation

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