A client who was rescued from a house fire is admitted to the burn unit with deep dermal, partial thickness (second degree) burns over approximately one-third of the back and upper thighs. The
nurse begins administration of prescribed crystalloid fluids for the first 24-hours following the burn incident. Which physiological response is promoted by the administration of the fluids?

Fluid resuscitation due to capillary leaking.

Replacement of insensible water loss.

Extension of plasma until blood is available.

Restoration of electrolyte balance.

Answer and Explanation

The Correct Answer is A

Rationale

A. In the early phase following a burn injury, there is increased capillary permeability due to the release of inflammatory mediators. This results in fluid shifting from the intravascular space into the interstitial space (capillary leaking), leading to hypovolemia and decreased tissue perfusion. Administering crystalloid fluids helps to restore intravascular volume (fluid resuscitation) and improve tissue perfusion.

B. Burn injuries can lead to increased evaporative water loss through damaged skin (insensible water loss). Crystalloid fluids help to replace this lost fluid and maintain adequate hydration status in the client.

C. In severe burn injuries, there may be a need for blood transfusions due to hemorrhage or ongoing blood loss. Crystalloid fluids can help to extend plasma volume temporarily until blood products are available for transfusion, thereby supporting circulatory stability.

D. Burn injuries can disrupt electrolyte balance due to fluid shifts and tissue damage. Crystalloid fluids contain electrolytes (such as sodium and chloride) that help to restore and maintain electrolyte balance in the body.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale

A. Granola and strawberries may be high in fiber, which could potentially worsen diarrhea in some individuals. Tea is generally fine, but it should be non-caffeinated to avoid further irritation to the digestive system.

B. Whole wheat toast can be a good option as it provides carbohydrates for energy without being too heavy. However, coffee is caffeinated and can stimulate bowel movements and increase gastric acid secretion, potentially aggravating diarrhea.

C. Oatmeal is gentle on the stomach and provides soluble fiber, which can help absorb water and bulk up stools. Banana is a good source of potassium, which may be lost during episodes of diarrhea. Herbal tea is non-caffeinated and can help hydrate.

D. Sausage and milk can be high in fat and lactose, which may be difficult to digest, especially during diarrhea. Poached eggs are generally well tolerated, but the overall combination may not be ideal for someone with diarrhea.

A. The client seems unemotional when talking about needing to rebuild her house. B. The client says that she sometimes forgets why she is in the hospital. C. The client discusses moving to Hawaii instead of returning to rebuild her house. D. The client is frightened that the hospital will burn down.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.

Suppression fits here because the client appears detached or unemotional when discussing the significant emotional task of rebuilding her house after it collapsed. This suggests a deliberate effort to suppress or minimize the emotional impact of the situation.

Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.

The client's discussion of moving to Hawaii instead of facing the reality of rebuilding her house reflects a form of fantasy. It suggests a retreat into an idealized scenario (moving to a distant, idyllic location) to avoid dealing directly with the trauma and stress associated with rebuilding her home.

Client Statement: B. The client says that she sometimes forgets why she is in the hospital.

Isolation can be inferred here because the client's statement about forgetting why she is in the hospital may indicate a psychological distancing or detachment from the traumatic events that led her there. It suggests a coping mechanism where she separates her emotional distress (related to the house collapse) from the practical reality of being hospitalized and receiving treatment.

Client Statement: D. The client is frightened that the hospital will burn down.

This statement fits into the defense mechanisms of fantasy. The client encounters thoughts of the hospital burning and her house burns down.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

Correct Answer is C

Explanation

Exhibits Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.

Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.

Client Statement: B. The client says that she sometimes forgets why she is in the hospital.

Client Statement: D. The client is frightened that the hospital will burn down.

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether findings suggest that the client's condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?