The nurse is assisting a burn-injured patient to select foods that promote wound healing. Which statement indicates the knowledge of the nurse regarding nutritional goals for this patient?

Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal

Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing.

Choose foods that are high in protein, such as meat, eggs and beans. These help the burns to heal

It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will provide energy and help with healing faster

Answer and Explanation

The Correct Answer is C

A. Saturated fats do not directly interfere with wound healing. While excessive intake of unhealthy fats should be minimized for overall health, fats themselves are not the primary focus when promoting wound healing in burn patients.

B. Fiber is important for digestive health but does not directly affect wound healing in burn patients. Protein and calories are more important for supporting tissue repair and overall healing.

C. Protein is essential for tissue repair, wound healing, and immune function, making it a priority nutrient for burn patients. High-protein foods support the increased metabolic demands of healing and help rebuild damaged tissues.

D. While carbohydrates are important for energy, protein plays a more significant role in wound healing. A balance of carbohydrates and protein is ideal, but protein is the primary nutrient needed for tissue repair in burn patients.

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Correct Answer is C

Explanation

A. Respiratory rate 20/min: A respiratory rate of 20/min is within the normal range for an adolescent. While respiratory function should always be monitored, this finding is not alarming in the context of blunt trauma.

B. Heart rate 72/min: A heart rate of 72/min is within the normal range for an adolescent. This does not indicate immediate concern, and the patient’s heart rate is stable.

C. Blood pressure 89/50 mm Hg: A blood pressure of 89/50 mm Hg is low and indicates potential shock, which is a life-threatening concern. Hypotension following blunt abdominal trauma can suggest internal bleeding or organ injury, which requires immediate intervention.

D. Abdominal pain rated 4 on a scale of 0 to 10: While abdominal pain is a concern, a pain level of 4/10 is not immediately life-threatening. The priority is addressing the low blood pressure, which could indicate shock or internal bleeding, requiring urgent medical attention.

A. Increase in the heart rate from 88 to 90/min B. Increase in the temperature from 99.5 °F to 100 °F C. Decrease in the respiratory rate from 20 to 16/min. D. Decrease in the urinary output from 50 mL to 30 mL per hour

Correct Answer is D

Explanation

A. Increase in the heart rate from 88 to 90/min: A heart rate increase of 2/min is not significant to indicate hypovolemic shock. In the early stages of hypovolemic shock, a more pronounced increase in heart rate is expected as a compensatory mechanism for low blood volume.

B. Increase in the temperature from 99.5°F to 100°F: A slight increase in temperature is common postoperatively and is generally not indicative of hypovolemic shock. A more concerning sign would be a fever that is significantly elevated or a rapid temperature change in combination with other symptoms.

C. Decrease in the respiratory rate from 20 to 16/min: A decrease in respiratory rate is not typically a sign of hypovolemic shock. In shock, respiratory rate often increases as the body compensates for decreased oxygen perfusion.

D. Decrease in the urinary output from 50 mL to 30 mL per hour: As the body experiences decreased perfusion due to blood loss, the kidneys are less able to filter and excrete urine. A decrease in urinary output indicates poor renal perfusion, which is a sign of shock.

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The nurse is assisting a burn-injured patient to select foods that promote wound healing. Which statement indicates the knowledge of the nurse regarding nutritional goals for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nursing priority?

Correct Answer is C

Explanation

A nurse is caring for a client who returns to the nursing unit from the recovery room after a colon resection. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Correct Answer is D

Explanation

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