While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

Assess papillary reactions to light.

Measure and record abdominal girth.

Auscultate over main stem bronchus.

Determine time of last oral intake.

Answer and Explanation

The Correct Answer is C

A. Assessing papillary reactions to light is important in a neurological assessment but is not the priority in this situation.

B. Measuring and recording abdominal girth is not relevant to the client's current symptoms.

C. Auscultating over the main stem bronchus is the priority action as the client's symptoms suggest potential airway compromise, possibly from inhalation injury or swelling. Early identification and management of airway issues are critical in burn patients.

D. Determining the time of last oral intake is part of a comprehensive assessment but is not the immediate priority when airway compromise is suspected.

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Correct Answer is C

Explanation

A. While explaining medications for anxiety is helpful, understanding the client's specific fears is crucial for addressing their concerns effectively.

B. Reviewing the home health care plan is important but should follow addressing the client's immediate concerns and fears about going home.

C. Asking the client about their fears helps to address specific concerns and provides an opportunity to offer targeted support and reassurance.

D. While privacy is important, it is not as critical as understanding and addressing the client's fears directly.

A. Focus on small achievable tasks, not taxing problems. B. Analyze past hurts and resentments to identify the source. C. Relax and reduce the amount of effort to solve the problem. D. Concentrate on and ventilate emotions when distressed.

Correct Answer is A

Explanation

A. Focusing on small achievable tasks helps to build a sense of accomplishment and reduce anxiety by breaking down overwhelming problems into manageable steps.

B. Analyzing past hurts may be useful in therapy, but for immediate coping, focusing on small tasks is more practical.

C. Relaxing and reducing effort might lead to avoidance rather than addressing anxiety.

D. Ventilating emotions is important but focusing on small tasks is more directly actionable for coping with anxiety and improving daily functioning.

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While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

Nursing Test Bank

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