The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands.
Which finding would the nurse expect to note in this condition?

Red skin with edema in the nail beds.

Black fingertips surrounded by an erythematous rash.

A white appearance to the skin that is insensitive to touch.

A pink edematous hand.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Red skin with edema in the nail beds is more indicative of a superficial injury or inflammation, such as cellulitis or a mild burn, rather than frostbite.

Choice B rationale

Black fingertips surrounded by an erythematous rash suggest gangrene or severe necrosis, which can occur in advanced stages of frostbite but is not an initial finding.

Choice C rationale

A white appearance to the skin that is insensitive to touch is a classic sign of frostbite. The lack of sensation is due to the freezing of tissues and nerves, and the white color indicates a lack of blood flow to the affected area.

Choice D rationale

A pink edematous hand is more indicative of a mild inflammatory response or early stages of frostbite before the tissue has frozen. It does not represent the more severe presentation of frostbite.

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Correct Answer is ["B","D","E"]

Explanation

Choice B rationale

Nausea is a common symptom of digoxin toxicity. Elevated levels of digoxin can lead to gastrointestinal disturbances, including nausea, vomiting, and loss of appetite.

Choice D rationale

Seeing halos around bright objects is a classic sign of digoxin toxicity. This visual disturbance, along with blurred vision and yellow-green vision, indicates that the digoxin level is too high.

Choice E rationale

Photophobia, or sensitivity to light, can also be a symptom of digoxin toxicity. This occurs due to the effects of digoxin on the visual system.

A. Medicate for pain. B. Maintain the airway. C. Insert an indwelling urinary catheter. D. Initiate fluid resuscitation.

Correct Answer is B

Explanation

Choice A rationale

While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.

Choice B rationale

Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.

Choice C rationale

Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.

Choice D rationale

Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.

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The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client prescribed digoxin to help manage heart failure. Which manifestations correlate with a digoxin level of 2.3 ng/dL? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?

Correct Answer is B

Explanation

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The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands.
Which finding would the nurse expect to note in this condition?