Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

Improved wound healing

Allergic reaction in patients with sulfa allergies

Delayed wound healing

Increased risk of infection

Answer and Explanation

The Correct Answer is B

A. Improved wound healing:

While silver sulfadiazine is used to promote wound healing by preventing and treating infections in burn victims, this is not an adverse reaction. This is an intended therapeutic effect of the medication.

B. Allergic reaction in patients with sulfa allergies:

Silver sulfadiazine contains sulfa, and patients who have a sulfa allergy may experience an allergic reaction. This can range from mild skin rashes to severe systemic reactions and is considered a significant adverse reaction.

C. Delayed wound healing:

Silver sulfadiazine is generally used to promote wound healing by preventing bacterial infections. Delayed wound healing is not a common adverse reaction but may occur in some cases due to other underlying factors or if the medication is not effective against certain bacteria.

D. Increased risk of infection:

The primary purpose of silver sulfadiazine is to reduce the risk of infection in burn wounds. An increased risk of infection would indicate a failure of the medication, not an adverse reaction. The correct potential adverse reaction is an allergic response in patients with a known sulfa allergy.

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Correct Answer is C

Explanation

(a) Inquire about family history of headaches:

While understanding the client's family history of headaches can be important for a comprehensive assessment, it is not the immediate priority. The description of "the worst headache" ever experienced could indicate a serious condition that needs urgent attention.

(b) Review the client's medical record:

Reviewing the client's medical record provides valuable information about their history and potential underlying conditions. However, given the severity of the reported headache, it is crucial to perform a more immediate physical assessment to rule out life-threatening conditions.

Assessing the client's blood pressure is a critical initial action. A severe headache can be a symptom of hypertensive crisis, stroke, or other serious conditions. High blood pressure could provide an immediate clue to the severity and cause of the headache, allowing for quicker intervention.

(d) Provide medication for pain relief:

Providing pain relief is important, but it should not be the first action without determining the cause of the headache. Administering medication without assessing the client's condition could mask symptoms of a potentially serious underlying issue such as a stroke or hypertensive emergency.

A. 20 represents the distance you are placed from the chart and 40 represents the distance a normal eye read the chart. B. 20 represents the distance a normal eye can read and 40 represents the distance your eye read the chart. C. 20 represents the distance you are placed from the chart and 40 represents the distance your eye read the chart. D. 40 represents the distance you are placed from the chart and 20 represents the distance a normal eye read the chart.

Correct Answer is A

Explanation

A. 20 represents the distance you are placed from the chart and 40 represents the distance a normal eye reads the chart:

This is correct. The first number (20) represents the distance in feet the patient is from the Snellen chart. The second number (40) indicates the distance at which a person with normal vision can read the same line. Therefore, 20/40 means that what the patient can read at 20 feet, a person with normal vision can read at 40 feet.

B. 20 represents the distance a normal eye can read and 40 represents the distance your eye reads the chart:

This is incorrect. The first number should represent the distance the patient is from the chart, not the normal eye's reading distance.

C. 20 represents the distance you are placed from the chart and 40 represents the distance your eye reads the chart:

This is incorrect. While the first number is correct (the distance from the chart), the second number should represent the distance a person with normal vision can read the same line, not the patient's distance.

D. 40 represents the distance you are placed from the chart and 20 represents the distance a normal eye reads the chart:

This is incorrect. The standard for visual acuity measurements is that the first number represents the testing distance (usually 20 feet), and the second number represents the distance at which a normal eye can read the line.

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Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action/Priority should the nurse perform next?

Correct Answer is C

Explanation

A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

Correct Answer is A

Explanation

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer.

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

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