A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take?

Place the client on a low-carbohydrate diet.

Monitor the client's calorie intake daily.

Place the client on strict bed rest.

Weigh the client once per week.

Answer and Explanation

The Correct Answer is B

A) Place the client on a low-carbohydrate diet:
A low-carbohydrate diet is not appropriate for a client with full-thickness burns, as their nutritional needs are significantly increased due to the high metabolic demands of wound healing. A high-calorie, high-protein diet is usually recommended to support recovery and manage the increased energy expenditure associated with burn injuries.

B) Monitor the client's calorie intake daily:
Daily monitoring of calorie intake is crucial for clients with significant burn injuries. Burns increase metabolic demands, and the client’s nutritional needs must be closely tracked to ensure adequate caloric and protein intake, which is essential for wound healing and overall recovery. Regular monitoring helps adjust dietary needs as required.

C) Place the client on strict bed rest:
Strict bed rest is not indicated for clients with burns, as mobility and physical therapy are important for maintaining muscle strength and preventing complications like contractures. While rest is important, a balanced approach involving gradual mobilization is preferred to support functional recovery.

D) Weigh the client once per week:
Weekly weighing may not be frequent enough for clients with burn injuries, as their weight can fluctuate significantly due to changes in fluid status and nutritional needs. More frequent monitoring is necessary to ensure that the client is receiving adequate nutrition and to assess their overall progress.

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Correct Answer is D

Explanation

A) Decreased responsiveness of airways to allergens:
Asthma is characterized by an increased responsiveness of the airways to various triggers, including allergens, rather than a decreased responsiveness. This heightened sensitivity leads to bronchoconstriction and inflammation, contributing to the symptoms of an asthma attack.

B) Suppressed bronchiolar inflammatory response:
During an asthma attack, there is an exaggerated bronchiolar inflammatory response rather than suppression. Inflammatory mediators cause swelling, mucus production, and constriction of the airways, making it difficult for the client to breathe.

C) Acute loss of alveolar elasticity:
The loss of alveolar elasticity is more characteristic of conditions like emphysema rather than asthma. Asthma primarily involves the airways rather than the alveoli, with symptoms resulting from bronchoconstriction and inflammation rather than loss of elasticity.

D) Inability to exhale retained carbon dioxide:
During an acute asthma attack, bronchoconstriction and airway inflammation lead to air trapping and difficulty in exhaling. This results in the retention of carbon dioxide and subsequent respiratory distress. The inability to exhale effectively exacerbates symptoms, making it a key contributing factor to the manifestations of an asthma attack.

A. "If you don't take this medication, you will feel worse." B. "Most clients feel better after taking the antibiotic." C. "I will tell your provider that you do not want to take this medication." D. "Your provider wouldn't prescribe this medication if it weren't necessary."

Correct Answer is D

Explanation

A) "If you don't take this medication, you will feel worse":
While this statement might be intended to convey the importance of the medication, it can come across as a threat or ultimatum. It does not engage with the client's concerns or offer a rationale for the medication's necessity.

B) "Most clients feel better after taking the antibiotic":
This response focuses on the general outcome rather than addressing the specific client's concerns or explaining why the medication is necessary for their condition. It may not provide the client with enough information to understand the importance of the medication.

C) "I will tell your provider that you do not want to take this medication":
This response shifts the responsibility to the provider without addressing the client's concerns directly. It is important to engage with the client and provide education about the medication before escalating the issue to the provider.

D) "Your provider wouldn't prescribe this medication if it weren't necessary":
This response acknowledges the client's concerns while providing a rationale for why the medication is important. It reinforces that the medication is prescribed based on medical necessity, aligning with the provider's judgment and emphasizing the importance of following the treatment plan.

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A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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