One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

Explain the need for skin exposure to sunlight without sunscreen.

Teach the need for dietary and supplemental vitamin D.

Instruct the client in the use of muscle strengthening exercises.

Encourage progressive active range of motion.

Answer and Explanation

The Correct Answer is B

Choice A reason: Explaining the need for skin exposure to sunlight without sunscreen is not advisable because it can increase the risk of further skin damage or skin cancer, especially in a client with a history of severe burns. Sunscreen should be used to protect the skin from harmful UV rays.

Choice B reason: Teaching the need for dietary and supplemental vitamin D is important because clients with extensive burns often have impaired vitamin D synthesis due to reduced exposure to sunlight and possible nutritional deficiencies. Vitamin D is essential for bone health and muscle function.

Choice C reason: Instructing the client in the use of muscle strengthening exercises is beneficial for overall health, but it does not directly address the specific issue of bone pain and muscle weakness related to potential vitamin D deficiency.

Choice D reason: Encouraging progressive active range of motion is important for maintaining joint flexibility and function, but it does not directly address the underlying cause of bone pain and muscle weakness in this scenario.

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Correct Answer is D

Explanation

Choice A reason: Administering normal saline solution alone will not address the severe anemia caused by the low hemoglobin level.

Choice B reason: Obtaining additional consent is necessary, but it is not the immediate action required in this emergency situation.

Choice C reason: Rechecking the client's hemoglobin, blood type, and Rh factor is important, but the immediate priority is to address the severe anemia.

Choice D reason: Transfusing Type A negative blood is appropriate because it is compatible with AB negative blood and is necessary to treat the client's critical anemia.

A. Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client. B. Introduce him to the newly admitted client and ask him to join in the conversation. C. Encourage him to go to the nurse's station and talk with another nurse. D. Inform him that the nurse is busy admitting a new client and will talk to him later.

Correct Answer is D

Explanation

Choice A reason: Ignoring the client can escalate the behavior, as individuals with antisocial behavior may act out more to gain attention.

Choice B reason: Introducing him to the newly admitted client and asking him to join the conversation can disrupt the admission process and does not address the client's behavior appropriately.

Choice C reason: Encouraging him to go to the nurse's station and talk with another nurse may be an option, but it does not directly address the client's need for immediate attention.

Choice D reason: Informing him that the nurse is busy and will talk to him later sets clear boundaries and allows the nurse to complete the admission process without disruption.

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One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

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Correct Answer is D

Explanation

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Correct Answer is D

Explanation

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

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