When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? (Select all that apply.)

Sloughing tissue around wound edges.

Change in the quality of the peripheral pulses.

Weeping serosanguineous fluid from wounds.

Loss of sensation to the left lower extremity.

Complaint of increased pain and pressure.

Answer and Explanation

Correct Answer : B,D,E

These findings suggest potential complications and compromise to the client's circulation and nerve function, which require immediate attention.

Changes in the quality of peripheral pulses indicate alterations in blood flow and may suggest vascular compromise or decreased perfusion to the affected areas. This finding requires immediate intervention to prevent further damage and ensure adequate blood supply to the extremities.

Loss of sensation to the left lower extremity can be indicative of nerve injury or impaired peripheral nerve function. It is important to assess for nerve damage and address it promptly to prevent complications and maximize the client's recovery.

Complaints of increased pain and pressure are concerning because they may indicate the development of compartment syndrome, a serious complication in which pressure within the muscles and tissues builds up to dangerous levels. Prompt intervention is necessary to relieve the pressure and prevent tissue damage.

While sloughing tissue around wound edges and weeping serosanguineous fluid from wounds are important assessment findings in the context of burn care, they do not require immediate intervention compared to the findings mentioned above. These findings should still be addressed and managed appropriately, but they are not considered immediate emergencies.

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Correct Answer is C

Explanation

A) Incorrect- Clarify reality with the client about delusional thoughts: Attempting to correct the client's delusional thoughts might cause frustration and agitation. Clients with Alzheimer's disease may have difficulty comprehending and retaining reality-based information.
B) Incorrect- Reduce the client's interaction with others during the day: Social interaction is important for clients with Alzheimer's disease to maintain engagement and prevent feelings of isolation. Reducing interaction could worsen their emotional well-being.
C) Correct- Clients with Alzheimer's disease often experience cognitive impairments and may have delusional thoughts or confusion, such as believing deceased loved ones are still alive. Nonpharmacological interventions are crucial to provide comfort and manage challenging behaviors. Distraction techniques involve redirecting the client's attention away from the delusion and onto a different, engaging activity. This can help decrease distress and anxiety related to their delusional thoughts. Therapeutic communication skills, such as validating the client's feelings and emotions, can also be beneficial. Simply telling the client that their mother is deceased may cause distress and confusion. Instead, providing comfort, empathizing with their emotions, and redirecting their focus can be more effective in managing the situation.
D) Incorrect- Awaken the client for reality checks every 4 hours at night: Disrupting the client's sleep schedule could lead to increased confusion and restlessness. It's important to provide a calm and consistent sleep routine for individuals with Alzheimer's disease.

A. Initiate a prescribed IV for parenteral fluid. B. Feed the infant 3 ounces of Isomil. C. Give the infant 5% dextrose in water orally. D. Insert a nasogastric tube for feeding.

Correct Answer is A

Explanation

The presenting symptoms of the infant, including persistent vomiting, poor skin turgor, significant weight loss, and a palpable abdominal mass, indicate a potential serious condition that requires immediate attention. These findings may suggest dehydration, malnutrition, and the presence of an abdominal mass that could be causing gastrointestinal obstruction or other underlying pathology.

Initiating a prescribed IV for parenteral fluid is the priority intervention to address the potential dehydration and fluid imbalance in the infant. This will help restore and maintain adequate hydration while further diagnostic evaluations and interventions are initiated.

Feeding the infant, giving 5% dextrose in water orally, or inserting a nasogastric tube for feeding should not be implemented as the first intervention in this case. It is important to stabilize the infant's fluid status before initiating oral feedings or other interventions to address the underlying cause of the symptoms.

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When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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