A client who was rescued from a house fire is admitted to the burn unit with deep dermal, partial thickness (second degree) burns over approximately one-third of the back and upper thighs. The
nurse begins administration of prescribed crystalloid fluids for the first 24-hours following the burn incident. Which physiological response is promoted by the administration of the fluids?

Fluid resuscitation due to capillary leaking.

Replacement of insensible water loss.

Extension of plasma until blood is available.

Restoration of electrolyte balance.

Answer and Explanation

The Correct Answer is A

Rationale

A. In the early phase following a burn injury, there is increased capillary permeability due to the release of inflammatory mediators. This results in fluid shifting from the intravascular space into the interstitial space (capillary leaking), leading to hypovolemia and decreased tissue perfusion. Administering crystalloid fluids helps to restore intravascular volume (fluid resuscitation) and improve tissue perfusion.

B. Burn injuries can lead to increased evaporative water loss through damaged skin (insensible water loss). Crystalloid fluids help to replace this lost fluid and maintain adequate hydration status in the client.

C. In severe burn injuries, there may be a need for blood transfusions due to hemorrhage or ongoing blood loss. Crystalloid fluids can help to extend plasma volume temporarily until blood products are available for transfusion, thereby supporting circulatory stability.

D. Burn injuries can disrupt electrolyte balance due to fluid shifts and tissue damage. Crystalloid fluids contain electrolytes (such as sodium and chloride) that help to restore and maintain electrolyte balance in the body.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.

Suppression fits here because the client appears detached or unemotional when discussing the significant emotional task of rebuilding her house after it collapsed. This suggests a deliberate effort to suppress or minimize the emotional impact of the situation.

Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.

The client's discussion of moving to Hawaii instead of facing the reality of rebuilding her house reflects a form of fantasy. It suggests a retreat into an idealized scenario (moving to a distant, idyllic location) to avoid dealing directly with the trauma and stress associated with rebuilding her home.

Client Statement: B. The client says that she sometimes forgets why she is in the hospital.

Isolation can be inferred here because the client's statement about forgetting why she is in the hospital may indicate a psychological distancing or detachment from the traumatic events that led her there. It suggests a coping mechanism where she separates her emotional distress (related to the house collapse) from the practical reality of being hospitalized and receiving treatment.

Client Statement: D. The client is frightened that the hospital will burn down.

This statement fits into the defense mechanisms of fantasy. The client encounters thoughts of the hospital burning and her house burns down.

A. Secure the room with padded walls and minimal furnishings. B. Provide one-on-one observation at all times. C. Release the client as soon as composure is regained. D. Observe for extrapyramidal symptoms, such as dystonia.

Correct Answer is D

Explanation

Rationale

A. While ensuring the room is secure and providing one-on-one observation are also important, the immediate concern after administering haloperidol is the potential for these side effects.

B. Continuous observation is crucial to monitor the client's behavior, mood, and safety while in seclusion. This allows the nurse to intervene promptly. However, monitoring should be specific

C. Seclusion is not intended as a punishment but as a therapeutic intervention to protect the client and others from harm during acute psychiatric episodes. The decision to release the client should be based on clinical assessment

D. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), including dystonia (muscle spasms). Monitoring for EPS is essential after administering haloperidol to ensure early detection and treatment, which may involve administering anticholinergic medications if EPS occurs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.

Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.

Client Statement: B. The client says that she sometimes forgets why she is in the hospital.

Client Statement: D. The client is frightened that the hospital will burn down.

Correct Answer is D

Explanation

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Exhibits The nurse is reviewing the chart. Select the condition from the choices below to fill in each blank in the following sentence. Based on the client's history and physical, the nurse notes that this postpartum client is most at risk for developing dropdown

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