Question 1: An adult client experiences a gasoline tank fire when riding a
motorcycle and is admitted to the emergency department (ED) with full
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burns to all surfaces of both lower extremities. What percentage of body surface
area should the nurse document in the electronic medical record (EMR)?
Options:
1. 9%
2. 18%
3. 36%
4. 45%
- Answer: 36%
Rationale: According to the rule of nines, the anterior and posterior surfaces of one
lower extremity are designated as 18% of total body surface area (TBSA), so both
extremities equal 36% TBSA. The other options are incorrect.
Question 2: A client with hyperthyroidism is receiving propranolol (Inderal).
Which finding indicates that the medication is having the desired effect?
Options:
1. Decrease in serum T4 levels
2. Increase in blood pressure
3. Decrease in pulse rate
4. Goiter no longer palpable
- Answer: Decrease in pulse rate
Rationale: Propranolol is a beta-blocker medication used to treat hyperthyroidism.
One of its effects is to decrease heart rate. The other options are unrelated to the
desired effect of the medication.
Question 3: An older male client with type 2 diabetes mellitus reports that he
experiences leg pain when walking short distances, and that the pain is relieved by
rest. Which client behavior indicates an understanding of healthcare teaching to
promote more effective arterial circulation?
Options:
1. Consistently applies TED hose before getting dressed in the morning.
2. Frequently elevates legs throughout the day.
3. Inspects the leg frequently for any irritation or skin breakdown
4. Completely stops cigarette/cigar smoking.
- Answer: Completely stops cigarette/cigar smoking.
Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and
improve arterial circulation to the extremities. The other options are not directly
related to arterial circulation.
Question 4: A community health nurse is concerned about the spread of
communicable diseases among migrant farm workers in a rural community. What
action should the nurse take to promote the success of a healthcare program
designed to address this problem?
Options: Establish trust with community leaders and respect cultural and family
values
- Answer: Establish trust with community leaders and respect cultural and family
values.
Question 5: The nurse performs a prescribed neurological check at the beginning
of the shift on a client who was admitted to the hospital with a subarachnoid brain
attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What
information is most important for the nurse to determine?
Options:
1. The client's previous GCS score
2. When the client's stroke symptoms started
3. If the client is oriented to time
4. The client's blood pressure and respiration rate
- Answer: The client's previous GCS score
Rationale: The normal GCS is 15, and it is most important for the nurse to
determine if the abnormal score is a sign of improvement or a deterioration in the
client's condition. [Show Less]