When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Deep partial thickness A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames.

When the emergency nurse learns that the patient suffered
injury from a flash flame, the nurse anticipates which depth of burn?
a) Deep partial thickness
A deep partial thickness burn is similar to a second-degree burn and is
associated with scalds and flash flames.
b) Superficial partial thickness
Superficial partial thickness burns are similar to first-degree burns and
are associated with sunburns.
c) Full thickness
Full thickness burns are similar to third-degree burns and are
associated with direct flame, electric current, and chemical contact.
d) Superficial
Injury from a flash flame is not associated with a burn that is limited
to the epidermis.
by

1 Answer

Answer :

a) Deep partial thickness
A deep partial thickness burn is similar to a second-degree burn and is
associated with scalds and flash flames.
by

Related questions

The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock? a) Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. b) Neurogenic Neurogenic shock is associated with spinal cord injury and anesthesia. c) Cardiogenic Cardiogenic shock is associated with disease of the heart. d) Anaphylactic Anaphylactic shock is associated with hypersensitivity reactions.

Description : The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock? a) Septic Septic shock is associated with immunosuppression, extremes of age, ... disease of the heart. d) Anaphylactic Anaphylactic shock is associated with hypersensitivity reactions.

Last Answer : a) Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures.

When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity. b) Vital capacity The nurse anticipates decreased vital capacity. c) Gas exchange and diffusing capacity The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. d) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Description : When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue ... ) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Last Answer : a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity.

When the nurse reviews the physician’s progress notes for the patient who has sustained a head injury and sees that the physician observed Battle’s sign when the patient was in the Emergency Department, the nurse knows that the physician observed a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

A new biosynthetic dressing used , is used to treat?in the treatment of burns, TransCyte a) burns of indeterminate depth is used to treat burns in which the depth is?TransCyte indeterminate or between superficial and deep partial thickness in depth.

Description : A new biosynthetic dressing used , is used to treat?in the treatment of burns, TransCyte a) burns of indeterminate depth is used to treat burns in which the depth is?TransCyte ... a temporary biosynthetic wound?BCG Matrix covering intended for use with partial-thickness burns and donor sites

Last Answer : a) burns of indeterminate depth is used to treat burns in which the depth is?TransCyte indeterminate or between superficial and deep partial thickness in depth.

Of the following stimuli, which is known to trigger an episode of autonomic hyperreflexia in the patient who has suffered a spinal cord injury? a) Applying a blanket over the patient An object on the skin or skin pressure may precipitate an autonomic hyperreflexic episode.

Description : Of the following stimuli, which is known to trigger an episode of autonomic hyperreflexia in the patient who has suffered a spinal cord injury? a) Applying a blanket over the patient An ... lower blood pressure. d) Voiding The most common cause of autonomic hyperreflexia is a distended bladder.

Last Answer : a) Applying a blanket over the patient An object on the skin or skin pressure may precipitate an autonomic hyperreflexic episode.

The nurse anticipates that the physician will perform joint aspiration and wrapping with compression elastic dressing for which of the following musculoskeletal problems? a) Joint effusion The described treatments are used with joint effusions and hemarthrosis.

Description : The nurse anticipates that the physician will perform joint aspiration and wrapping with compression elastic dressing for which of the following musculoskeletal problems? a) Joint effusion The described ... of tissue due to insufficient blood supply and may be associated with steroid use.

Last Answer : a) Joint effusion The described treatments are used with joint effusions and hemarthrosis.

The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Description : The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Last Answer : A. Gastric decompression

Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Description : Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to ... . Such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns.

Last Answer : a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to: a) decrease catabolism. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%.

Description : The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to: a) decrease catabolism. The most important intervention ... the energy source is seen after a burn injury; interventions are instituted to decrease catabolism.

Last Answer : a) decrease catabolism. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%.

If a case of smallpox is suspected, the nurse should a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office at 770-488-7100. The CDC will respond by immmediate provision of diagnostic support and eventual release of vaccine if a case is confirmed. Until instructed otherwise by the CDC, healthcare providers should carefully establish isolation with negative pressure, and maintain thorough lists of all those who have contact with the patient.

Description : If a case of smallpox is suspected, the nurse should a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office ... very different from that of chickenpox. With chickenpox, lesions appear at different developmental stages.

Last Answer : a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office at 770-488-7100. The CDC will respond by immmediate provision ... with negative pressure, and maintain thorough lists of all those who have contact with the patient.

Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or return to the ED if the patient a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

Description : Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or ... for short periods of time. Difficulty in waking the patient should be reported or treated immediately.

Last Answer : a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening. b) urgent. Urgent surgery means that the patient requires prompt attention within 24-30 hours. c) required. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. d) elective. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

Which of the following factors are associated with increased fluid requirements in the management of patients with burn injury? a) Inhalation injuries Factors associated with increased fluid requirements include inhalation injuries, delayed resuscitation, scald burn injuries, high-voltage electrical injuries, hyperglycemia, alcohol intoxification and chronic diuretic therapy.

Description : Which of the following factors are associated with increased fluid requirements in the management of patients with burn injury? a) Inhalation injuries Factors associated with increased fluid ... fluid requirements. d) Hypoglycemia Hypoglycemia is not associated with increased fluid requirements.

Last Answer : a) Inhalation injuries Factors associated with increased fluid requirements include inhalation injuries, delayed resuscitation, scald burn injuries, high-voltage electrical injuries, hyperglycemia, alcohol intoxification and chronic diuretic therapy.

Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

Description : When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi's sarcoma. Kaposi's sarcoma is ... syphilis. A painless chancre or ulcerated lesion is a typical finding in the patient with syphilis.

Last Answer : a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

When the patient who has undergone laryngectomy suffers wound breakdown, the nurse monitors him very carefully because he is identified as being at high risk for a) carotid artery hemorrhage. The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly. b) pulmonary embolism. Pulmonary embolism is associated with immobility. c) dehydration. Dehydration may lead to poor wound healing and breakdown. d) pneumonia. Pneumonia is a risk for any postoperative patient.

Description : When the patient who has undergone laryngectomy suffers wound breakdown, the nurse monitors him very carefully because he is identified as being at high risk for a) carotid artery hemorrhage. The ... poor wound healing and breakdown. d) pneumonia. Pneumonia is a risk for any postoperative patient.

Last Answer : a) carotid artery hemorrhage. The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly.

Which of the following terms refers to a graft derived from one part of a patient’s body and used on another part of that same patient’s body? a) Autograft Autografts of full-thickness and pedicle flaps are commonly used for reconstructive surgery, months or years after the initial injury.

Description : Which of the following terms refers to a graft derived from one part of a patient's body and used on another part of that same patient's body? a) Autograft Autografts of full-thickness and pedicle ... A heterograft is a graft obtained from an animal of a species other than that of the recipient.

Last Answer : a) Autograft Autografts of full-thickness and pedicle flaps are commonly used for reconstructive surgery, months or years after the initial injury.

Which of the following terms is used to refer to protrusion of abdominal organs through the surgical incision? a) Evisceration Evisceration is a surgical emergency. b) Hernia A hernia is a weakness in the abdominal wall. c) Dehiscence Dehiscence refers to partial or complete separation of wound edges. d) Erythema Erythema refers to redness of tissue.

Description : Which of the following terms is used to refer to protrusion of abdominal organs through the surgical incision? a) Evisceration Evisceration is a surgical emergency. b) Hernia A hernia is a weakness ... partial or complete separation of wound edges. d) Erythema Erythema refers to redness of tissue.

Last Answer : a) Evisceration Evisceration is a surgical emergency.

The Emergency Department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment? a) Rest, ice, compression, elevation RICE is used for the treatment of contusions, sprains, and strains.

Description : The Emergency Department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment? a) Rest, ice, compression ... contraindicated when injury is suspected, and examination, while indicated, does not provide treatment.

Last Answer : a) Rest, ice, compression, elevation RICE is used for the treatment of contusions, sprains, and strains.

79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, “How old is the client?” Holding the fallopian tube, the surgeon asks for a hemostat. The scrub nurse sensing that the surgeon is about to ligate the tube said, “Doctor there is no signed consent for tubal ligation.” The nurse just demonstrated which of the following?

Description : 79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, How old is the client? Holding the fallopian ... there is no signed consent for tubal ligation. The nurse just demonstrated which of the following?

Last Answer : C. Advocacy

Nurse Mercy is setting up for an emergency caesarian section. The linen packs were damp although these were just taken from the sterilizer. The nurse’s appropriate action is A. Bring the linen packs back to the Central Supply section for quality control B. Change the damp linen pack C. Open the linen pack and allow to dry D. Do not use the damp linen

Description : Nurse Mercy is setting up for an emergency caesarian section. The linen packs were damp although these were just taken from the sterilizer. The nurse's appropriate action is A. Bring the linen packs back to the ... linen pack C. Open the linen pack and allow to dry D. Do not use the damp linen

Last Answer : D. Do not use the damp linen

The term given to the category of triage that refers to lifethreatening or potentially life-threatening injury or illness requiring immediate treatment is a) emergent. The patient triaged as emergent must be seen immediately.

Description : The term given to the category of triage that refers to lifethreatening or potentially life-threatening injury or illness requiring immediate treatment is a) emergent. The patient triaged as emergent ... . The triage category of immediate refers to non-acute, non-lifethreatening injury or illness.

Last Answer : a) emergent. The patient triaged as emergent must be seen immediately.

Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Description : Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. ... rails and application of mitts are the appropriate interventions in the agitated head-injured patient.

Last Answer : a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a) Widened pulse pressure Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature.

Description : Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a) Widened pulse pressure Additional signs of increasing ICP ... regarded as unfavorable because hyperthermia may indicate brain stem damage, a poor prognostic sign.

Last Answer : a) Widened pulse pressure Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature.

When the nurse auscultates chest sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together, she records her finding as a) pleural friction rub. A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. b) crackles. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. c) sonorous wheezes. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. d) sibilant wheezes. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

Description : When the nurse auscultates chest sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together, she records her finding as a) pleural friction rub. A ... wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

Last Answer : a) pleural friction rub. A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid.

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

Description : Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and ... only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

Last Answer : a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

When the patient has been field triaged and categorized as blue, the nurse recognizes that the patient requires a) fast-track or psychological support. When a patient is categorized as blue, field triage has identified fasttrack or psychological support needs.

Description : When the patient has been field triaged and categorized as blue, the nurse recognizes that the patient requires a) fast-track or psychological support. When a patient is categorized as blue, field ... . d) urgent care. Field triaged patients who require urgent care will be categorized as green.

Last Answer : a) fast-track or psychological support. When a patient is categorized as blue, field triage has identified fasttrack or psychological support needs.

The nurse teaches the parent of the child with chickenpox that the child is no longer contagious to others when a) the vesicles and pustules have crusted. When the lesions have crusted, the patient is no longer contagious to others.

Description : The nurse teaches the parent of the child with chickenpox that the child is no longer contagious to others when a) the vesicles and pustules have crusted. When the lesions have crusted, the ... , and pustules appear. The child remains contagious when the rash is changing into vesicles and pustules.

Last Answer : a) the vesicles and pustules have crusted. When the lesions have crusted, the patient is no longer contagious to others.

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

Description : The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in ... severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

Last Answer : a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse recognizes that the patient is likely demonstrating signs of a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

Description : When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse ... heterotrophic ossification. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

Last Answer : a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Description : The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out ... alcohol and caffeine consumption in moderation, and performing a regular weight-bearing exercise regimen.

Last Answer : a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise ... and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

When the nurse notes that the patient’s left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) hammertoe. Hammertoes are usually pulled upward. c) pes cavus. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Description : When the nurse notes that the patient's left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) ... the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Last Answer : a) hallux valgus. Hallux valgus is commonly referred to as a bunion.

The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems. Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems; do not cover it with plastic or rubber.

Description : The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin ... A broken cast should be reported to the physician; the patient should not attempt to fix it.

Last Answer : a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems. Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems; do not cover it with plastic or rubber.

In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

Description : When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the ... are removed routinely. Traction must be continuous to be effective in reducing and immobilizing fractures.

Last Answer : a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes. b) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. c) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger. d) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Description : Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to ... the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Last Answer : a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes.

Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve. b) Peroneal The peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes. c) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. d) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Description : Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation ... The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Last Answer : a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve.

The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Description : The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to ... output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Last Answer : a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B may cause fever, chills and body aches. The administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to the administration of amphotericin B may prevent these side effects.

Description : A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of ... and cerebral spinal fluid (CSF) cultures. Blood and CSF cultures help diagnosis fungal encephalitis.

Last Answer : a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B ... 30 minutes prior to the administration of amphotericin B may prevent these side effects.

The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign - a blood stain surrounded by a yellowish stain. The nurse knows that this sign a) is highly suggestive of a cerebrospinal fluid (CSF) leak. The halo sign - a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.

Description : The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign - a blood stain surrounded by a yellowish stain. The nurse knows that this sign a) is highly ... following a basal skull fracture. The halo sign is highly suggestive of a cerebrospinal fluid (CSF) leak.

Last Answer : a) is highly suggestive of a cerebrospinal fluid (CSF) leak. The halo sign - a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.

A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin a) can greatly increase the international normalization ratio (INR) and therefore increase the risk of bleeding. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

Description : A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken ... headaches. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

Last Answer : a) can greatly increase the international normalization ratio (INR) and therefore increase the risk of bleeding. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

A patient has had neurologic deficits lasting for more than 24 hours, and now the symptoms are resolving. The nurse concludes that the patient has had which type of stroke? a) Reversible ischemic neurologic deficit With a reversible ischemic neurologic deficit, the patient has more pronounced signs and symptoms that last more than 24 hours; symptoms resolve in a matter of days without any permanent neurologic deficit.

Description : A patient has had neurologic deficits lasting for more than 24 hours, and now the symptoms are resolving. The nurse concludes that the patient has had which type of stroke? a) Reversible ... and symptoms have stabilized with no indication of further progression of the hypoxic insult to the brain.

Last Answer : a) Reversible ischemic neurologic deficit With a reversible ischemic neurologic deficit, the patient has more pronounced signs and symptoms that last more than 24 hours; symptoms resolve in a matter of days without any permanent neurologic deficit.

When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient’s posturing as a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

Description : When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's ... rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Last Answer : a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles towards the magnet.

Description : What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the ... oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.

Last Answer : a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen ... literally be pulled away with such great force that they can fly like projectiles towards the magnet.

The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could become activated with exposure to strong light, such as sunlight or bright lights. Ordinary indoor light is not a problem. The patient should be counseled to wear protective clothing, such as long-sleeved shirts, sunglasses, and wide-brimmed hats, if the patient has to go outdoors during daylight hours in the first five days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Description : The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. ... should avoid exposure to direct sunlight or bright lights for the first five days post-treatment.

Last Answer : a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could ... days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

Description : When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person ... 20/20 line, the person of normal vision will be standing at a distance of 20 feet from the chart.

Last Answer : a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Description : When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement ... Pancrease. Commercially available enzymatic debriding agents include Accuzyme, Clooagenase, Granulex, and Zymase.

Last Answer : a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

The nurse teaches the patient who demonstrates herpes zoster (shingles) that a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity.

Description : The nurse teaches the patient who demonstrates herpes zoster (shingles) that a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a ... is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

Last Answer : a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity.

The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

Description : The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a ... . d) local arterial insufficiency. Local arterial insufficiency is characterized by marked localized pallor.

Last Answer : a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.