A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?

Schedule meals at 6-hr intervals.

Maintain calorie intake at 1,500 per day.

Keep a calorie count for foods and beverages.

Provide a low-protein, high-carbohydrate diet.

Answer and Explanation

The Correct Answer is C

A. Scheduling meals at 6-hour intervals is inadequate as clients with major burns require frequent, high-calorie intake.

B. A calorie intake of 1,500 per day is insufficient for burn clients, who require significantly higher caloric intake to support healing.

C. Keeping a calorie count helps ensure the client is meeting their increased nutritional needs for wound healing and recovery.

D. A high-protein, high-carbohydrate diet is necessary, not a low-protein diet, to support tissue repair and metabolic demands.

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Correct Answer is C

Explanation

A. Widened pulse pressure (not narrowed) is associated with increased ICP.

B. Bradycardia (not tachycardia) is commonly seen in increased ICP due to Cushing’s triad.

C. An increasingly severe headache is a key sign of rising ICP due to increased pressure on pain-sensitive structures.

D. Hypertension, not hypotension, is a characteristic of increased ICP.

A. "Make sure to use nearby furniture to support yourself when walking to the bathroom." B. "I will have the physical therapist ambulate you to the bathroom." C. "Tell me what concerns you have about using a bed pan." D. "You have to use the bed pan for your own safety."

Correct Answer is C

Explanation

A. Encouraging the client to use nearby furniture is unsafe for a client on complete bed rest.

B. Physical therapy is not typically called to assist with bathroom use for an end-of-life client.

C. This response acknowledges the client’s emotional state and opens communication to address their concerns empathetically.

D. Telling the client they "have to" use a bed pan without further discussion may come across as dismissive or insensitive.

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A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago. Which in the client's findings are potential indication of increased intracranial pressure?

Correct Answer is C

Explanation

A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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