When providing information to a client in the rehabilitative phase of a burn injury, which of the following will the nurse identify as the goal?
Resume a functional role in society
Pain management
Provide continued full support to the client
Prevent infection
The Correct Answer is A
Choice A reason: This is correct because resuming a functional role in society is the ultimate goal for a client in the rehabilitative phase of a burn injury. The rehabilitative phase begins when wound healing is complete and lasts until physical and psychosocial recovery is achieved. The nurse should help the client regain independence, self-esteem, and quality of life by providing education, counseling, referrals, and resources.
Choice B reason: This is incorrect because pain management is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Pain management is important throughout all phases of burn care, but especially during wound healing and scar formation, which can cause itching, tightness, or hypersensitivity. The nurse should assess the client's pain level and administer analgesics, antipruritics, or moisturizers as ordered.
Choice C reason: This is incorrect because providing continued full support to the client is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Providing continued full support to the client can help them cope with physical and emotional challenges, such as scarring, disfigurement, disability, or depression. The nurse should provide emotional support, active listening, positive feedback, and encouragement to the client.
Choice D reason: This is incorrect because preventing infection is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Preventing infection is crucial during wound healing and grafting, which can be compromised by bacterial colonization or contamination. The nurse should monitor the client's vital signs, wound appearance, and laboratory results, and administer antibiotics or antiseptics as ordered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because nystagmus is not a response to stimuli, but a condition that causes involuntary eye movements. Nystagmus can be caused by various factors, such as inner ear disorders, brain lesions, or drug toxicity, but not necessarily by cervical spine injury.
Choice B Reason: This is incorrect because decorticate positioning is a response to stimuli that indicates damage to the cerebral cortex or the corticospinal tract. Decorticate positioning is characterized by flexion of the arms and extension of the legs. It does not indicate cervical spine injury, which affects the spinal cord below the brainstem.
Choice C Reason: This is incorrect because lack of any response to stimuli can indicate various levels of brain damage or coma, but not specifically cervical spine injury. Lack of any response can also be influenced by other factors, such as sedation, hypothermia, or shock.
Choice D Reason: This is correct because decerebrate positioning is a response to stimuli that indicates damage to the brainstem or the upper cervical spine. Decerebrate positioning is characterized by extension and outward rotation of the arms and legs. It indicates a severe and life-threatening injury that can impair vital functions, such as breathing and blood pressure.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because bacterial meningitis is a medical emergency that requires immediate antibiotic therapy to prevent complications and death.
Choice B reason: This is incorrect because documenting intake and output is not a priority action for a child with bacterial meningitis. Fluid balance is important, but not as urgent as antibiotic administration.
Choice C reason: This is incorrect because reducing environmental stimuli is a supportive measure that can help reduce headache and photophobia, but it is not a priority action for a child with bacterial meningitis. The nurse should focus on preventing infection spread and monitoring for signs of increased intracranial pressure.
Choice D reason: This is incorrect because maintaining seizure precautions is a preventive measure that can help protect the child from injury, but it is not a priority action for a child with bacterial meningitis. The nurse should administer anticonvulsants as prescribed and observe for seizure activity, but the main goal is to treat the infection.
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