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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Aspirin does have analgesic properties, which help relieve pain. However, this is not the primary reason for its administration in the context of angina-like chest pain. The analgesic effect of aspirin without sedation is more relevant in the management of general pain or headaches.

Choice B reason: Vasoconstriction and improved blood flow are not effects of aspirin. In fact, aspirin's mechanism of action involves preventing platelet aggregation, which can indirectly improve blood flow by reducing the risk of clot formation. Vasoconstriction is not an effect associated with aspirin.

Choice C reason: The primary rationale for administering aspirin to a client with angina-like chest pain is its antiplatelet effect. Aspirin inhibits platelet aggregation, reducing the risk of clot formation. This is crucial in preventing further blockage of coronary arteries, which can exacerbate angina or lead to myocardial infarction.

Choice D reason: Cardiotonic properties and improved contraction are not associated with aspirin. Cardiotonic drugs enhance the strength of the heart's contractions, which is not an action of aspirin. Aspirin's role in this context is to prevent platelet aggregation and reduce the risk of clot-related complications.

A. Suction every 2 hours. B. Provide rest periods between nursing procedures. C. Encourage active range of motion. D. Assign the patient to a semiprivate room near the nurse's station.

Correct Answer is B

Explanation

Choice A reason: Suctioning every 2 hours is not appropriate for a patient with increased intracranial pressure (ICP). Suctioning can increase ICP due to the stress and stimulation it causes. It should only be performed when absolutely necessary and with proper precautions to minimize ICP spikes.

Choice B reason: Providing rest periods between nursing procedures is the correct measure. This helps minimize stimulation and stress, which can increase ICP. Rest periods allow the patient to stabilize and reduce the risk of further increasing the pressure within the skull.

Choice C reason: Encouraging active range of motion exercises is not suitable for a patient with increased ICP. Physical activity can exacerbate the condition by increasing intracranial pressure. The focus should be on minimizing activity and stress to prevent further elevation of ICP.

Choice D reason: Assigning the patient to a semiprivate room near the nurse's station is not the best approach. Patients with increased ICP require a quiet and calm environment to help manage their condition. A semiprivate room near the nurse's station may expose the patient to more noise and activity, which could increase ICP.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse correlates which rationale with the administration of aspirin to the client experiencing angina-like chest pain?

Correct Answer is C

Explanation

Which of these measures is appropriate for a patient diagnosed with increased intracranial pressure?

Correct Answer is B

Explanation

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