A nurse is caring for a child who received partial-thickness burns to over 50% of his body 10 days ago and has splints over his joints to prevent contractures. Which of the following actions should the nurse take? (Select all that apply.)
Provide a high-calorie det
Monitor intake and output.
Change dressings using aseptic technique
Remove splints during sleep
Administer analgesics IM
Correct Answer : A,B,C
A. Providing a high-calorie diet is important for a child with extensive burns to support wound healing and recovery.
B. Monitoring intake and output is crucial to assess fluid balance and ensure that the child is receiving enough fluids and nutrients for healing.
C. Changing dressings using an aseptic technique helps prevent infection, which is a significant risk in burn wounds.
D. Removing splints during sleep is not recommended, as they are in place to prevent contractures. They should be worn consistently, including during sleep.
E. Administering analgesics IM (intramuscularly) is not typically indicated. Pain
management can be achieved through various routes, and IM administration may not be necessary. Additionally, it's important to consider the child's pain level and choose the most appropriate and effective route for analgesia.
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Related Questions
Correct Answer is D
Explanation
A. Tremors are not a typical clinical manifestation of heart failure. They may be associated with conditions like hyperthyroidism or certain medications.
B. Bradycardia (slow heart rate) is not a typical finding in heart failure. In fact, tachycardia (fast heart rate) is more commonly associated with this condition.
C. Increased appetite is not a typical clinical manifestation of heart failure. Children with heart failure may actually experience poor appetite due to decreased cardiac output.
D. Correct. Tachypnea (rapid breathing) is a common clinical manifestation of heart
failure. It can occur as the body tries to compensate for the decreased cardiac output by increasing respiratory rate in an effort to maintain oxygenation.
Correct Answer is A
Explanation
A. This statement demonstrates an understanding of a helpful strategy for managing encopresis. Having the child try to defecate 15 minutes after each meal can take advantage of the body's natural reflexes and increase the likelihood of regular bowel movements.
B. Limiting fluid intake is not a recommended strategy for managing encopresis.
Maintaining proper hydration is important for overall health.
C. Having the child sit on the toilet for extended periods of time may lead to frustration and aversion to toilet training. It is not a recommended approach.
D. Increasing dairy intake is not a specific strategy for managing encopresis. In fact, some dairy products can contribute to constipation in some individuals. A balanced diet with an appropriate amount of fiber is important for bowel regularity.
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