Which is the greatest concern during the emergent phase of a burn injury?

joint contractures

hypovolemic shock.

Fluid overload

adrenal failure

Answer and Explanation

The Correct Answer is B

A. Joint contractures are a long-term concern, not an immediate threat during the emergent phase.
B. Hypovolemic shock due to fluid loss is a primary concern in the emergent phase of a burn injury.
C. Fluid overload is not a primary concern in the emergent phase, though it could be a concern in the later resuscitative phase.
D. Adrenal failure is not typically an immediate concern in the emergent phase of burn care.

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Correct Answer is D

Explanation

A. Very disruptive to a person in society: This description is judgmental and not specific to documenting behavior objectively.

B. Differing from socially acceptable behavior: Documenting behavior as differing from socially acceptable norms provides an objective, non-judgmental account of the patient’s behavior.

C. Causing the person to be involved in problems: This focuses on the outcomes of the behavior rather than describing the behavior itself.

D. Resulting from an inability to exercise control: This may imply a lack of control but does not objectively describe the behavior for documentation purposes.

A. "What we say can be secret. What I write in the chart is available to the health team." B. "I am required to report any intent to hurt yourself or others." C. "Conversations between patient and nurse are confidential." D. "I can't help you unless you trust me."

Correct Answer is B

Explanation

A. "What we say can be secret. What I write in the chart is available to the health team." This response lacks clarity about legal and ethical obligations.
B. "I am required to report any intent to hurt yourself or others." This response clearly communicates the legal and ethical obligation to protect the patient and others from harm, while also acknowledging the importance of patient confidentiality in other situations.
C. "Conversations between patient and nurse are confidential." This is true, but it does not address exceptions such as harm to self or others.
D. "I can't help you unless you trust me." This does not address the patient's concerns about confidentiality directly.

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Which is the greatest concern during the emergent phase of a burn injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient admitted to the hospital after a motorcycle crash that has left him paralyzed from the waist down tells the nurse he has feelings of helplessness and hopelessness. What other feelings may the patient have that should be recognized?

Correct Answer is D

Explanation

The patient is concerned about confidentiality and asks the nurse not to tell anyone what is said. What is the best response by the nurse?

Correct Answer is B

Explanation

A nurse is caring for an older adult who lives in a long-term care facility on the Alzheimer unit. Every evening around 5:00 p.m., the resident becomes increasingly agitated and more confused, a state that lasts throughout the evening. The nurse recognizes this behaviour as:

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For what is the older adult patient at increased risk because of age-related changes in the musculoskeletal system?

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