A nurse is caring for a school-age child who has full-thickness burns to 30% of the total body surface area (TBSA). The nurse is initiating the client's plan of care. Complete the following sentence by using the list of options.
The client is at highest risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Choice A reason: Hypovolemia is a condition of low blood volume due to fluid loss from the burn injury. It can cause decreased urine output, hypotension, tachycardia, and poor skin turgor. The nurse should monitor the client's vital signs, fluid intake and output, and weight. The nurse should administer lactated Ringer's solution to maintain urine output of 30 ml/hr.
Choice B reason: Hyperkalemia is a condition of high potassium levels in the blood due to cellular damage from the burn injury. It can cause peaked T waves, dysrhythmias, muscle weakness, and cardiac arrest. The nurse should monitor the client's serum potassium levels, electrocardiogram, and cardiac status. The nurse should avoid administering potassium-containing fluids or medications.
Choice C reason: Hypocalcemia is a condition of low calcium levels in the blood due to fluid shifts from the burn injury. It can cause positive Chvostek's sign, tetany, seizures, and hypotension. The nurse should monitor the client's serum calcium levels, neurological status, and blood pressure. The nurse should administer calcium supplements as prescribed.
Choice D reason: Hypernatremia is a condition of high sodium levels in the blood due to fluid loss from the burn injury. It can cause dry mucous membranes, thirst, agitation, and seizures. The nurse should monitor the client's serum sodium levels, hydration status, and mental status. The nurse should administer hypotonic fluids as prescribed.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason: This is not a correct statement by the child. The child should take their regular insulin as prescribed, even when they are sick. Insulin helps the body use glucose for energy and prevents high blood sugar levels, which can cause complications. The child may need to adjust their insulin dose or frequency depending on their blood glucose levels, food intake, and activity level.
Choice B reason: This is not a correct statement by the child. The child should not store unopened bottles of insulin in the freezer. Freezing can damage the insulin and make it ineffective. The child should store unopened bottles of insulin in the refrigerator, away from direct light and heat. The child should store opened bottles of insulin at room temperature and discard them after 28 days.
Choice C reason: This is not a correct statement by the child. The child's morning blood glucose should be between 70 and 110 mg/dL, according to the American Diabetes Association. A blood glucose level between 90 and 130 mg/dL may indicate that the child has hyperglycemia, or high blood sugar, which can cause symptoms such as thirst, hunger, fatigue, and frequent urination.
Choice D reason: This is a correct statement by the child. The child should eat a snack half an hour before playing soccer or engaging in any physical activity. Physical activity lowers blood glucose levels, and a snack can help prevent hypoglycemia, or low blood sugar, which can cause symptoms such as shakiness, sweating, dizziness, and confusion.
Correct Answer is A
Explanation
Choice A reason: Bacterial meningitis is an inflammation of the meninges, the membranes that cover the brain and spinal cord, caused by a bacterial infection. It can cause fever, headache, neck stiffness, photophobia, and altered mental status. The cerebrospinal fluid (CSF) analysis may show increased white blood cells, protein, and glucose. The nurse should assess the neck range of motion and the reaction to pupil assessment, as these may indicate increased intracranial pressure.
Choice B reason: Encephalitis is an inflammation of the brain tissue, usually caused by a viral infection. It can cause fever, headache, confusion, seizures, and focal neurological deficits. The CSF analysis may show increased white blood cells and protein, but normal glucose. The nurse should assess the level of consciousness and the neurological status, as these may indicate brain damage.
Choice C reason: Gastroenteritis is an inflammation of the stomach and intestines, usually caused by a viral or bacterial infection. It can cause nausea, vomiting, diarrhea, abdominal pain, and dehydration. The nurse should assess the gastrointestinal manifestations and the vital signs, as these may indicate fluid and electrolyte imbalance.
Choice D reason: Migraine is a type of headache that involves recurrent episodes of moderate to severe pain, usually on one side of the head, often accompanied by nausea, vomiting, and sensitivity to light and sound. The nurse should assess the location and duration of pain, the triggers and relievers, and the history of migraine. The CSF analysis is usually normal.
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