The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?

Monitor for signs of seizure activity.

Increase the IV rate and monitor for burn shock.

Raise the foot of the bed and apply blankets.

Assess for signs of fluid overload.

Answer and Explanation

The Correct Answer is D

A. Monitor for signs of seizure activity: Seizure activity is not directly related to the condition described.
B. Increase the IV rate and monitor for burn shock: Increasing the IV rate could exacerbate fluid overload; burn shock is more of a concern in the initial hours post-burn.
C. Raise the foot of the bed and apply blankets. This is not relevant to addressing the issue of large urine output.
D. Assess for signs of fluid overload: After the initial fluid resuscitation phase, large urine output may indicate that fluid is being mobilized from the tissues back into the vascular system, potentially leading to fluid overload.

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Correct Answer is A

Explanation

A. Obsessive-compulsive: This behavior involves persistent, intrusive thoughts (obsessions) and repetitive behaviors (compulsions) aimed at reducing anxiety, fitting the definition of obsessive-compulsive disorder.

B. Anxiety tension: Anxiety tension is a broader term and does not specifically address the repetitive checking behavior seen in obsessive-compulsive disorder.

C. Controlled repetition: This term is not commonly used to describe a specific psychological condition related to repeated behaviors due to obsessive thoughts.

D. Senseless behavior: The behavior is not senseless but is driven by anxiety and obsessive-compulsive tendencies.

A. Fever B. A decrease in venous return C. Orthostatic hypotension D. Dehydration

Correct Answer is C

Explanation

A. Fever: Fever can cause weakness or dizziness, but it is not a sudden cause of falling when getting up.
B. A decrease in venous return can contribute to orthostatic hypotension but is not a direct cause on its own.
C. Orthostatic hypotension is a common cause of sudden falls in older adults when they change positions, leading to dizziness or fainting.
D. Dehydration can lead to orthostatic hypotension but is not as direct a cause of sudden falls when getting up as orthostatic hypotension itself.

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The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?

Nursing Test Bank

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