A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond?

"I suggest that you get control of yourself”

"Please stop yelling. I brought dinner as soon as I could”

"Do you need something for pain right now?"

"You seem upset. I have time to talk if you'd like”

Answer and Explanation

The Correct Answer is D

A. "I suggest that you get control of yourself": This response is judgmental and dismissive of the client's feelings. It does not acknowledge the client's emotional state or offer a supportive approach to address their anger.

B. "Please stop yelling. I brought dinner as soon as I could": This response focuses on justifying the nurse's actions and does not acknowledge the client's emotional needs. It also shuts down the conversation by demanding the client stop yelling, rather than addressing their feelings.

C. "Do you need something for pain right now?": While the client may need pain management, this response doesn't address the client's anger which might be related to stress or frustration. It overlooks the opportunity to understand the root cause of the outburst.

D. "You seem upset. I have time to talk if you'd like.": This response is empathetic and non-confrontational. It acknowledges the client's emotional state and offers a space for them to express their feelings. It shows willingness to listen, which can help de-escalate the situation and provide emotional support.

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Correct Answer is A

Explanation

A. External cardiac pacemaker: If atropine is ineffective in treating symptomatic sinus bradycardia, the next step is the use of an external cardiac pacemaker which helps regulate the heart rate by providing electrical stimulation to the heart, addressing the bradycardia and improving circulation.

B. Amiodarone: Amiodarone is an antiarrhythmic drug used for treating ventricular arrhythmias or atrial fibrillation, not for bradycardia. The priority for bradycardia management is pacing rather than antiarrhythmic medications.

C. Magnesium: Magnesium is primarily used for treating specific arrhythmias like torsades de pointes, particularly in the presence of hypomagnesemia. It is not indicated for symptomatic sinus bradycardia, especially after atropine fails.

D. Cardioversion: Cardioversion is used to treat arrhythmias such as atrial fibrillation or supraventricular tachycardia, not bradycardia. Since the issue is a slow heart rate, not an abnormal rhythm needing electrical shock, cardioversion is not appropriate in this case.

A. Sterile gauze bandages to the bleeding lacerations B. Cervical spine protective collar C. Pillow under the back of the knees to promote blood return to the heart D. Inflatable air cast on the right arm

Correct Answer is B

Explanation

A. Sterile gauze bandages to the bleeding lacerations: While it is important to address bleeding, the priority in a trauma situation, especially after ejection from a vehicle, is to stabilize the spine and prevent potential cervical spine injury.

B. Cervical spine protective collar: Given the mechanism of injury (MOI) — being ejected from a vehicle — the risk of a cervical spine injury is high. A cervical spine protective collar is the priority to prevent potential spinal cord damage, as the neck may have been subjected to significant forces during the accident.

C. Pillow under the back of the knees to promote blood return to the heart: While positioning can help with comfort and blood circulation, the priority in this case is stabilizing the cervical spine to prevent further injury, not promoting blood return.

D. Inflatable air cast on the right arm: The open fracture of the right ulnar bone requires immobilization, but stabilizing the cervical spine takes precedence in a trauma situation. The arm injury will be addressed after the patient's spine is secured.

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A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has symptomatic sinus bradycardia. The Atropine was given but was not successful. Which one of the following is the next intervention?

Correct Answer is A

Explanation

You are caring for a patient who was ejected from a vehicle during a bad car accident on the freeway. Your patient has an open fracture of the right ulnar bone and multiple small lacerations. Based on the mechanism of injury (MOI) what would be a priority to place on the patient?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid-base balances?

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

A client whose heart monitor shows sinus tachycardia, is apneic and has no palpable pulses. What action should the nurse ta next?

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

A nurse is assessing a client who is in the early stages of hypoxia. Which of the following assessment findings should the nurse expect?

Which assessment finding obtained by the nurse when caring for a client receiving mechanical ventilation indicates the need for suctioning?