The nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. For what reason does the nurse assess the patient's abdomen?
To perform daily full head-to-toe assessment.
To assess for a paralytic ileus secondary to reduced blood flow.
To assess for nausea and vomiting related to pain medication.
To monitor increased motility that may result in cramps and diarrhea.
The Correct Answer is B
Choice A reason: While performing a daily full head-to-toe assessment is important in comprehensive patient care, this answer does not specifically address why the nurse would be particularly concerned with assessing the abdomen in a burn patient.
Choice B reason: Assessing for a paralytic ileus secondary to reduced blood flow is crucial in patients with serious burns. Burns can lead to significant physiological stress, which can decrease blood flow to the gastrointestinal tract. This reduction in blood flow can cause a paralytic ileus, a condition where the intestines do not move properly, leading to abdominal distention, pain, and decreased bowel sounds. Early detection is vital to prevent complications.
Choice C reason: While nausea and vomiting related to pain medication are possible in burn patients, the primary concern in assessing the abdomen would be to identify more serious conditions such as a paralytic ileus. This answer does not capture the immediate criticality compared to assessing for paralytic ileus.
Choice D reason: Monitoring for increased motility that may result in cramps and diarrhea is not the primary concern in burn patients. In fact, burn patients are more likely to experience decreased gastrointestinal motility due to the stress response and reduced blood flow rather than increased motility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The client with mitral valve stenosis experiencing heart palpitations is at risk of complications such as atrial fibrillation, which can lead to embolic events. While this is a serious condition that needs attention, it is not as immediately life-threatening as the presence of pink frothy sputum in a heart failure patient.
Choice B reason: The client with arterial occlusive disease and intermittent claudication is experiencing pain due to reduced blood flow to the extremities during activity. Although this condition requires management to prevent worsening ischemia, it is not as critical as the presentation of pink frothy sputum in a heart failure patient.
Choice C reason: The client with deep vein thrombosis (DVT) and an edematous right calf is at risk of developing a pulmonary embolism, which is a serious condition. However, the immediate symptoms do not suggest a current life-threatening emergency compared to the client with heart failure and pink frothy sputum.
Choice D reason: The client with heart failure who has pink frothy sputum must be assessed first. Pink frothy sputum is a sign of pulmonary edema, indicating severe left-sided heart failure. This condition is a medical emergency as it impairs gas exchange and can lead to respiratory failure if not promptly treated. Immediate intervention is necessary to stabilize the client's respiratory and cardiac status.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Age is a non-modifiable risk factor for coronary artery disease. While it is a significant risk factor, individuals cannot change their age. Modifiable risk factors are those that individuals can alter through lifestyle changes or medical interventions to reduce their risk of developing coronary artery disease.
Choice B reason: Hypertension, or high blood pressure, is a modifiable risk factor for coronary artery disease. By managing blood pressure through lifestyle changes, medications, and regular monitoring, individuals can reduce their risk of developing coronary artery disease. Effective management of hypertension includes reducing sodium intake, maintaining a healthy weight, exercising regularly, and taking prescribed medications.
Choice C reason: Obesity is a modifiable risk factor for coronary artery disease. Individuals can work towards achieving and maintaining a healthy weight through dietary changes, increased physical activity, and behavioral modifications. Losing weight can significantly lower the risk of coronary artery disease by improving blood pressure, cholesterol levels, and overall cardiovascular health.
Choice D reason: Smoking is a major modifiable risk factor for coronary artery disease. Quitting smoking can dramatically reduce the risk of developing coronary artery disease and other cardiovascular conditions. Smoking cessation programs, medications, and support groups can help individuals successfully quit smoking and improve their cardiovascular health.
Choice E reason: Stress is a modifiable risk factor for coronary artery disease. Chronic stress can contribute to the development of coronary artery disease by affecting blood pressure, cholesterol levels, and overall heart health. Managing stress through relaxation techniques, exercise, counseling, and mindfulness practices can help reduce the risk of coronary artery disease.
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