Which of the following assessments should the nurse prioritize for a burn patient with impaired physical mobility?

Assessing for rhinorrhea or otorrhea

Monitoring for changes in the client's baseline focused assessment

Documenting the relevant information in the client's medical record

Range of motion (ROM) of the restrained extremity

Answer and Explanation

The Correct Answer is B

A. Assessing for rhinorrhea or otorrhea:
Relevant in head trauma or skull fracture, not a priority in impaired mobility related to burns.

B. Monitoring for changes in the client's baseline focused assessment:
Changes in perfusion, sensation, and mobility may indicate compartment syndrome or pressure injuries and need prompt attention.

C. Documenting the relevant information in the client's medical record:
Important for continuity of care, but not the priority assessment.

D. Range of motion (ROM) of the restrained extremity:
Helpful to prevent contractures, but monitoring for clinical deterioration takes precedence.

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Correct Answer is B

Explanation

A. Apply dry, sterile gauze dressings to affected areas
Shingles lesions are usually left open to air or covered with non-adherent dressings. Dry gauze may adhere to lesions and cause trauma.

B. Prepare to administer acyclovir
Acyclovir is an antiviral medication used to reduce severity and duration of herpes zoster (shingles) symptoms.

C. Apply topical corticosteroids to the affected areas
Topical corticosteroids are not recommended for herpes zoster as they can worsen viral infections.

D. Instruct family with a history of chickenpox that they should not visit the client
People who have had chickenpox are immune to varicella-zoster virus and can visit safely. Only individuals without prior exposure or vaccination should avoid contact.

A. Reddish brown dots at the base of hairs B. Large, fluid-filled blisters C. Gray blue macules on the thighs and axillae D. Short, wavy, brownish black lines

Correct Answer is D

Explanation

A. Reddish brown dots at the base of hairs:
Suggestive of lice/nits, not scabies.

B. Large, fluid-filled blisters:
Could indicate bullous impetigo or burns, not typical of scabies.

C. Gray blue macules on the thighs and axillae:
These may be seen in pubic lice, but not scabies.

D. Short, wavy, brownish black lines:
These are burrows made by the scabies mite, often seen in web spaces, wrists, or axillae.

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Which of the following assessments should the nurse prioritize for a burn patient with impaired physical mobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The nurse is caring for a patient with lesions on the skin. Which of the following assessment findings would cause the nurse to suspect scabies?

Correct Answer is D

Explanation

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