A nurse is caring for a client with partial-thickness and full-thickness burns on the head, neck, and chest.
What is the primary risk to the client?
Contractures
Fluid imbalance
Airway obstruction
Infection .
The Correct Answer is C
Choice A rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can be a complication of burns. However, they are not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice B rationale
While fluid imbalance can occur with any burn due to loss of fluid from the damaged skin, it is not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice C rationale
Airway obstruction is a primary risk for a patient with burns on the head, neck, and chest. Swelling from the burns can lead to obstruction of the airway, making it difficult for the patient to breathe.
Choice D rationale
While infection is a risk with any burn, it is not typically the primary risk for a patient with burns on the head, neck, and chest. The primary risk is airway obstruction due to swelling from the burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A patient with type 1 diabetes who has taken a high dose of insulin is at the highest risk for developing hypoglycemia. Insulin lowers blood glucose levels, and taking a high dose can cause the levels to drop too low.
Choice B rationale
A patient with type 2 diabetes who has not taken any medication is not at a high risk for developing hypoglycemia. Without medication, their blood glucose levels may be high, not low.
Choice C rationale
An elderly patient who is taking an antibiotic for an infection is not at a high risk for developing hypoglycemia. Antibiotics do not typically affect blood glucose levels.
Choice D rationale
A patient with metabolic syndrome who is taking a statin to lower cholesterol levels is not at a high risk for developing hypoglycemia. Statins do not typically affect blood glucose levels.
Correct Answer is D
Explanation
Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.
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