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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Depression is more related to a sense of loss or prolonged stress, not immediate perceived threats.
B. Anxiety is an emotional response to a perceived threat, involving worry and fear about potential danger.
C. Fear is a direct response to a known and definite threat, whereas anxiety is more about anticipation of a threat.
D. Anger can result from frustration or perceived injustice but is not primarily driven by perceived threats to self.
Correct Answer is A
Explanation
A. Alzheimer's disease is the most common cause of dementia, accounting for a majority of cases.
B. Parkinson disease can cause dementia, but it is less common than Alzheimer's disease.
C. Medications: Certain medications can cause reversible cognitive impairment but are not the most common cause of dementia.
D. Multi infarct dementia (vascular dementia) is a common cause, but Alzheimer's disease is more prevalent.
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