While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

Assess papillary reactions to light.

Measure and record abdominal girth.

Auscultate over main stem bronchus.

Determine time of last oral intake.

Answer and Explanation

The Correct Answer is C

A. Assessing papillary reactions to light is important in a neurological assessment but is not the priority in this situation.

B. Measuring and recording abdominal girth is not relevant to the client's current symptoms.

C. Auscultating over the main stem bronchus is the priority action as the client's symptoms suggest potential airway compromise, possibly from inhalation injury or swelling. Early identification and management of airway issues are critical in burn patients.

D. Determining the time of last oral intake is part of a comprehensive assessment but is not the immediate priority when airway compromise is suspected.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

Pressure injuries: These can indicate neglect or inadequate care, as they often develop from prolonged periods of immobility or poor hygiene.

Poor hygiene: A foul odor and unclean environment, along with a lack of clothing, can be signs of neglect or mistreatment.

Malnutrition: The client's low weight (98 lb or 44.5 kg) and a lack of appropriate nutrition could indicate inadequate care and potential mistreatment, contributing to overall poor health and well-being.

A. Administer 2 mg of diazepam intravenously. B. Induce paralysis. C. Apply cooling blankets. D. Apply 1 L/min oxygen. E. Ensure that the antidepressant medication is discontinued

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Diazepam is a benzodiazepine that can be effective in managing symptoms of serotonin syndrome, including agitation and myoclonus. It can help reduce muscle rigidity and provide sedation.

Inducing paralysis is not appropriate in this scenario. The patient’s symptoms suggest serotonin syndrome or another type of stimulant intoxication, and paralysis could worsen the situation or mask underlying symptoms.

The patient has a high fever (102°F or 38.8°C) and significant diaphoresis. Cooling blankets can help manage hyperthermia and reduce body temperature.

The patient’s oxygen saturation is 97% on room air, indicating adequate oxygenation. There is no immediate need for supplemental oxygen at this time.

If the patient is suspected to have serotonin syndrome, which can be triggered by the use of certain antidepressants (particularly SSRIs), discontinuing the offending medication is crucial.

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While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse reviews the findings in the history and physical. Drag from Word Choices to complete the sentence. The nurse recognizes that dropdown, dropdown, and dropdownare findings consistent with elder mistreatment.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

Patient Data Exhibits The nurse reviews the prescriptions and assessment data. Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)?

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