The patient talks with his dead brother and arranges furniture so that his brother will have a place to sit. How should the nurse document this behavior?

Alogia

Disordered thinking

Hallucination

Anhedonia

Answer and Explanation

The Correct Answer is C

A. Alogia: Alogia refers to poverty of speech or a reduction in the amount of speech, not to hallucinations.
B. Disordered thinking: Disordered thinking involves a disruption in logical thought processes but does not specifically describe interacting with non-existent entities.
C. Hallucination: A hallucination is a sensory perception (in this case, visual and possibly auditory) in the absence of an external stimulus. Talking to and arranging furniture for a deceased brother fits this definition.
D. Anhedonia: Anhedonia refers to the inability to experience pleasure, not to hallucinations or disordered perceptions.

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Correct Answer is F

Explanation

A. Insert nasogastric tube: A nasogastric tube may be inserted early to prevent aspiration and manage gastric distension.
B. Initiate fluid therapy: Fluid therapy is crucial and initiated early to combat hypovolemic shock.
C. Insert Foley catheter: A Foley catheter is often inserted early to monitor urine output and assess renal function.
D. Establish airway: Establishing an airway is the highest priority intervention for burn victims, especially if there are signs of inhalation injury.
E. Administer analgesics: Pain management is crucial but is initiated early in the treatment process.
F. Tetanus prophylaxis: Tetanus prophylaxis is important to prevent infection but is typically administered after the immediate life-threatening issues have been addressed.

A. Within 12 hours after burn trauma B. 48 to 72 hours after burn trauma C. 24 to 36 hours after burn trauma D. 36 to 48 hours after burn trauma

Correct Answer is B

Explanation

A. Within 12 hours after burn trauma: Fluid loss is significant initially but peaks later.

B. 48 to 72 hours after burn trauma: The greatest fluid loss typically occurs within the first 48 to 72 hours as capillary permeability is at its highest and fluid resuscitation needs are greatest.

C. 24 to 36 hours after burn trauma: Fluid loss is still considerable but not at its peak; the peak is generally observed a bit later.

D. 36 to 48 hours after burn trauma: Fluid loss continues to be high, but the peak is generally reached a little later than this timeframe.

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The patient talks with his dead brother and arranges furniture so that his brother will have a place to sit. How should the nurse document this behavior?

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Naxlex Comprehensive Predictor Exams

What is the last intervention for a hospitalized severely burned victim during the emergent phase?

Correct Answer is F

Explanation

A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?

Correct Answer is B

Explanation

The nurse is caring for a patient who is being treated with antipsychotic medications. As part of the plan of care, the nurse monitors the patient for dyskinesia. What would the nurse assess with dyskinesia?

The nurse concludes that a significant goal of the care plan for an alcoholic patient has been met when the patient makes which statement?

What coping mechanism demonstrated by a patient should indicate to the nurse that the patient is seeking ways to deal with and resolve stress?

A perceived threat to self causes what emotion?

When communicating with an older adult patient who has difficulty hearing, how should the nurse change her speech?

Which is the term for an infection of a hair follicle?

A patient who has sustained a burn injury will undergo wound debridement. The nurse includes which explanation when explaining the purpose of burn wound debridement?

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