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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Most Likely Condition:
Herpes zoster (Shingles): The client presents with a painful, burning, unilateral rash in a dermatomal distribution with grouped vesicles on an erythematous base — classic for herpes zoster (shingles). The shoulder x-ray is normal, ruling out musculoskeletal causes.
Actions to Take:
Anticipate administering an antiviral medication: Antiviral medications like acyclovir, valacyclovir, or famciclovir reduce the severity and duration of shingles if started early.
Request a prescription analgesic medication: Shingles is often extremely painful. Ibuprofen was ineffective, so stronger analgesics are likely needed.
Parameters to Monitor:
Pain: Pain monitoring assesses the effectiveness of analgesic and antiviral treatment.
Post-herpetic neuralgia (nerves): Monitoring for lingering nerve pain is crucial, as shingles can lead to long-term nerve damage.
Correct Answer is D
Explanation
A. To prevent infection in burn wounds:
Analgesics like Dilaudid do not prevent infection; antibiotics and wound care do.
B. To promote wound healing in burn patients:
Pain control may aid indirectly, but opioids do not promote wound healing directly.
C. To decrease the risk of hypothermia in burn patients:
Hypothermia prevention involves warm blankets, warming devices, and fluid management-not PCA.
D. To provide controlled and individualized pain relief in burn patients:
PCA pumps allow patients to self-administer opioid analgesia, offering consistent, effective pain control with less risk of overdose when properly programmed.
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