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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The patient has decreased perceptions: This is a sign of panic anxiety, not necessarily severe anxiety.

B. The patient has increased motivation: Increased motivation is associated with mild to moderate anxiety.

C. The patient has a feeling of impending doom: This is a hallmark of severe anxiety, characterized by intense fear and a sense of catastrophic events.

D. The patient could cause harm to self or others: This is more indicative of panic or extreme anxiety with loss of control.

A. "I wouldn't need to drink if I had my family back." B. "My drinking helps me cope with the stress of my job." C. "All my difficulties are related to my drinking." D. “I drink because I'm lonely."

Correct Answer is C

Explanation

A. "I wouldn't need to drink if I had my family back." This statement shifts the focus from personal responsibility for drinking to external factors.

B. "My drinking helps me cope with the stress of my job." This indicates a belief in using alcohol as a coping mechanism rather than recognizing the impact of drinking itself.

C. "All my difficulties are related to my drinking." Recognizing that difficulties are related to drinking shows insight and a step towards taking responsibility for the problem.

D. “I drink because I'm lonely.” While this indicates awareness of a trigger, it does not demonstrate the same level of insight into the central role of drinking in the patient’s difficulties.

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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?

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