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. Blepharitis is an inflammation of the eyelid margins, not related to lens elasticity.
B. Nearsightedness (myopia) is difficulty seeing distant objects, not typically age-related.
C. Cataracts involve clouding of the lens, not the loss of elasticity.
D. Presbyopia is the age-related loss of lens elasticity, resulting in difficulty focusing on close objects.
Correct Answer is A
Explanation
A. Bipolar disorder: The described behavior of extreme mood swings (elevated mood followed by significant depression) is characteristic of bipolar disorder.
B. Dysthymic disorder: Dysthymic disorder (now known as persistent depressive disorder) involves a chronic state of depression but does not typically feature such pronounced mood swings.
C. Hypomanic episode: A hypomanic episode would involve elevated mood but would not usually be followed by the severe depressive episode described.
D. Unipolar depression: Unipolar depression is characterized by a persistent low mood rather than the dramatic shifts described.
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