A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status.

Which of the following responses should the nurse make?

He has an electrical burn, which caused coagulation of some tissues

He is doing well, although he might be in the hospital for some time.

He does not appear to have much damage and should be fine soon

He has an electrical burn. He is stable, and we will update you with any changes.

Answer and Explanation

The Correct Answer is D

A. He has an electrical burn, which caused coagulation of some tissues:

This response provides more detailed information about the nature of the electrical burn, mentioning tissue coagulation. However, it may be more information than the family needs at this point, and it's important to balance providing information with respecting the client's privacy.

B. He is doing well, although he might be in the hospital for some time:

While this response aims to reassure the family about the client's general status, it might not be entirely accurate or provide specific information about the client's condition. It's important to be transparent while respecting the client's privacy.

C. He does not appear to have much damage and should be fine soon:

This response may provide a sense of reassurance to the family, but it might oversimplify the situation. It's important to provide accurate and honest information while respecting the client's privacy.

D. He has an electrical burn. He is stable, and we will update you with any changes:

This response acknowledges the type of injury, assures the family that the client is stable, and communicates a commitment to keeping the family informed of any changes. It strikes a balance between providing some information and maintaining the client's privacy and confidentiality.

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Correct Answer is A

Explanation

A. Check temperature and SPO2

When the nurse finds an adult patient's pulse rate to be 140 beats per minute, it is important to assess other vital signs, particularly temperature and oxygen saturation (SPO2). This helps gather additional information to understand the overall clinical picture and assess for potential underlying causes of the elevated heart rate.

B. Report the rate to the primary care provider:

Reporting the heart rate to the primary care provider may be necessary, but it should not be the immediate action. Assessing other vital signs first provides a more comprehensive understanding.

C. Check the pulse again in 2 hours:

Waiting for 2 hours to recheck the pulse is not appropriate when the heart rate is significantly elevated. Immediate action and further assessment are needed.

D. Record the information:

Recording the elevated heart rate is part of documentation, but it should be accompanied by a more comprehensive assessment of vital signs and potential contributing factors.

A. “Do you want to talk about your health concerns?” B. “Would it help to discuss your feelings about this hospitalization?” C. “Would you tell me about all of your medical issues?” D. “What brought you to the hospital?”

Correct Answer is D

Explanation

A. "Do you want to talk about your health concerns?"

While this question acknowledges the client's option to discuss health concerns, it is somewhat closed-ended and might not prompt the client to share specific details.

B. "Would it help to discuss your feelings about this hospitalization?"

This question addresses the client's feelings about the hospitalization, which is important for emotional well-being, but it might not directly elicit information about the client's primary health issues.

C. "Would you tell me about all of your medical issues?"

This question is somewhat open-ended but might be overwhelming for the client. It is more effective to start with a focused question about the reason for seeking care.

D. "What brought you to the hospital?"

This open-ended question encourages the client to share their primary reason for seeking healthcare and allows for a comprehensive discussion about the client's health concerns. It gives the client an opportunity to express their own perspective and share the relevant information about their medical condition or symptoms.

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A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status.

Which of the following responses should the nurse make?