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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Bacterial meningitis is a probable condition, as it is an infection of the membranes that cover the brain and spinal cord, caused by various bacteria, such as Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae. The adolescent has many signs and symptoms of bacterial meningitis, such as fever, headache, and neck stiffness.
Choice B reason: Viral meningitis is not a likely condition, as it is an infection of the membranes that cover the brain and spinal cord, caused by various viruses, such as enteroviruses, herpes simplex virus, or mumps virus. The adolescent has some signs and symptoms of viral meningitis, such as fever, headache, and neck stiffness, but they are usually less severe than bacterial meningitis.
Choice C reason: Encephalitis is not a probable condition, as it is an inflammation of the brain tissue, usually caused by viral infections, such as herpes simplex virus, West Nile virus, or rabies virus. The adolescent has some signs and symptoms of encephalitis, such as fever, headache, and altered mental status, but they are usually accompanied by focal neurological deficits, such as seizures, paralysis, or cranial nerve palsies.
Choice D reason: Brain abscess is not a definite condition, as it is a collection of pus within the brain tissue, usually caused by bacterial infections that spread from other parts of the body, such as the ear, sinus, or lung. The adolescent has some signs and symptoms of brain abscess, such as fever, headache, and altered mental status, but they are usually accompanied by focal neurological deficits, such as seizures, paralysis, or cranial nerve palsies.
Correct Answer is D
Explanation
Choice A reason: This is not a correct instruction for the nurse to include in the teaching. The Pavlik harness is a device that holds the infant's hips in a flexed and abducted position to allow the femoral head to fit into the acetabulum. The harness should not be removed by the parents, as this may interfere with the treatment and cause complications. The nurse should instruct the parents to sponge bathe the infant while wearing the harness.
Choice B reason: This is not a correct instruction for the nurse to include in the teaching. The length of the straps of the Pavlik harness should not be adjusted by the parents, as this may affect the alignment and stability of the infant's hips. The nurse should instruct the parents to bring the infant to the provider's office regularly for check-ups and adjustments of the harness.
Choice C reason: This is not a correct instruction for the nurse to include in the teaching. Massaging the infant's skin under the straps of the Pavlik harness may cause irritation, friction, or pressure on the skin, which may lead to skin breakdown or infection. The nurse should instruct the parents to keep the infant's skin clean and dry, and to check for any signs of redness, swelling, or drainage.
Choice D reason: This is a correct instruction for the nurse to include in the teaching. Placing the diaper under the straps of the Pavlik harness prevents the diaper from interfering with the position and function of the harness. The nurse should instruct the parents to change the diaper frequently and to avoid using bulky or cloth diapers.
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