The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?
Monitor for signs of seizure activity.
Increase the IV rate and monitor for burn shock.
Raise the foot of the bed and apply blankets.
Assess for signs of fluid overload.
The Correct Answer is D
A. Monitor for signs of seizure activity: Seizure activity is not directly related to the condition described.
B. Increase the IV rate and monitor for burn shock: Increasing the IV rate could exacerbate fluid overload; burn shock is more of a concern in the initial hours post-burn.
C. Raise the foot of the bed and apply blankets. This is not relevant to addressing the issue of large urine output.
D. Assess for signs of fluid overload: After the initial fluid resuscitation phase, large urine output may indicate that fluid is being mobilized from the tissues back into the vascular system, potentially leading to fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Moderate: Moderate anxiety typically involves increased alertness and focus, not severe physiological changes.
B. Panic: Panic is characterized by extreme dread and inability to function, often with a sense of unreality.
C. Mild: Mild anxiety involves slight discomfort and can enhance learning and performance.
D. Severe: Severe anxiety includes significant physiological responses (elevated vital signs) and a sense of impending doom.
Correct Answer is D
Explanation
A. Very disruptive to a person in society: This description is judgmental and not specific to documenting behavior objectively.
B. Differing from socially acceptable behavior: Documenting behavior as differing from socially acceptable norms provides an objective, non-judgmental account of the patient’s behavior.
C. Causing the person to be involved in problems: This focuses on the outcomes of the behavior rather than describing the behavior itself.
D. Resulting from an inability to exercise control: This may imply a lack of control but does not objectively describe the behavior for documentation purposes.
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