NURS 272 EXAM 4: TISSUE INTEGRITY AND MOBILITY
Which prevention strategy would the nurse include when teaching about home fire
safety?
a. Set hot water temperature at 140°F.
b. Use only hardwired smoke detectors.
c. Encourage regular home fire exit drills.
d. Do not allow older adults to cook unattended. - Answer -C. Encourage regular home
fire exit drills
The injury that is least likely to result in a full-thickness burn is
a. sunburn.
b. scald injury.
c. chemical burn.
d. electrical injury. - Answer -A. Sunburn
When assessing a patient with a partial-thickness burn, the nurse would expect to find
(select all that apply)
a. blisters.
b. exposed fascia.
c. exposed muscles.
d. intact nerve endings.
e. red, shiny, wet appearance. - Answer -a. blisters.
d. intact nerve endings.
e. red, shiny, wet appearance.
A patient is recovering from second- and third-degree burns over 30% of his body, and
the burn care team is planning for discharge. The first action the nurse should take
when meeting with the patient would be to
a. arrange a return-to-clinic appointment and prescription for pain medications.
b. teach the patient and the caregiver proper wound care to be performed at home.
c. review the patient's current health care status and readiness for discharge to home.
d. give the patient written information and websites for information for burn survivors. -
Answer -c. review the patient's current health care status and readiness for discharge to
home.
During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg
braces. Which level of injury does the nurse associate with this degree of recovery?
a. L1-2
b. T6-7
,c. T1-2
d. C7-8 - Answer -a. L1-2
A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous
system dysfunction. What would the nurse recognize as characteristic of this condition?
a. Tachycardia
b. Hypotension
c. Increased cardiac output
d. Peripheral vasoconstriction - Answer -b. Hypotension
A patient with spinal cord injury has severe neurologic deficits. What is the most likely
mechanism of injury for this patient?
a. Compression
b. Hyperextension
c. Flexion-rotation
d. Extension-rotation - Answer -c. Flexion-rotation
A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must
have the flu because he has a bad headache and nausea. The nurse's first priority is to
a. call the health care provider.
b. check the patient's temperature.
c. measure the patient's blood pressure.
d. elevate the head of the bed to 90 degrees. - Answer -c. measure the patient's blood
pressure.
The most common early symptom of a spinal cord tumor is
a. urinary incontinence.
b. back pain that worsens with activity.
c. paralysis below the level of involvement.
d. impaired sensation of pain, temperature, and light touch. - Answer -b. back pain that
worsens with activity.
During assessment of the patient with trigeminal neuralgia, the nurse should (select all
that apply)
a. inspect all aspects of the mouth and teeth.
b. assess the gag reflex and respiratory rate and depth.
c. lightly palpate the affected side of the face for edema.
d. test for temperature and sensation perception on the face.
e. ask the patient to describe factors that initiate an episode. - Answer -a. inspect all
aspects of the mouth and teeth.
d. test for temperature and sensation perception on the face.
,e. ask the patient to describe factors that initiate an episode.
During routine assessment of a patient with Guillain-Barré syndrome, the nurse finds
the patient is short of breath. The patient's respiratory distress is caused by
a. elevated protein levels in the CSF.
b. immobility resulting from ascending paralysis.
c. degeneration of motor neurons in the brainstem and spinal cord.
d. paralysis ascending to the nerves that stimulate the thoracic area. - Answer -d.
paralysis ascending to the nerves that stimulate the thoracic area.
A patient is admitted to the burn center with burns to his head, neck, and anterior and
posterior chest after an explosion in his garage. On assessment, the nurse auscultates
wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the
breath sounds are greatly decreased. Which action is the most appropriate for the nurse
to take next?
a. Encourage the patient to cough and auscultate the lungs again.
b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas.
c. Document the findings and continue to monitor the patient's breathing.
d. Anticipate the need for endotracheal intubation and notify the provider. - Answer -d.
Anticipate the need for endotracheal intubation and notify the provider.
Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury
include
a. adherence of albumin to vascular walls.
b. movement of potassium into the vascular space.
c. movement of sodium and water into the interstitial space.
d. hemolysis of red blood cells from large volumes of rapidly administered fluid. -
Answer -c. movement of sodium and water into the interstitial space.
To maintain a positive nitrogen balance in a major burn, the patient must
a. eat a high-protein, high-carbohydrate diet.
b. increase normal caloric intake by about four times.
c. eat at least 1500 calories/day in small, frequent meals.
d. eat a gluten-free diet for the chemical effect on nitrogen balance. - Answer -a. eat a
high-protein, high-carbohydrate diet.
A patient has 25% TBSA burn from a car fire. His wounds have been debrided and
covered with a silver-impregnated dressing. The nurse's priority intervention for wound
care would be to
a. reapply a new dressing without disturbing the wound bed.
b. observe the wound for signs of infection during dressing changes.
, c. apply cool compresses for pain relief in between dressing changes.
d. wash the wound aggressively with soap and water three times a day. - Answer -b.
observe the wound for signs of infection during dressing changes.
Pain management for the burn patient is most effective when (select all that apply)
a. a pain rating tool is used to monitor the patient's level of pain.
b. painful dressing changes are delayed until the patient's pain is completely relieved.
c. the patient is informed about and has some control over the management of the pain.
d. a multimodal approach is used (e.g., sustained-release and short-acting opioids,
NSAIDs, adjuvant analgesics).
e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the
rehabilitation phase of a burn injury. - Answer -a. a pain rating tool is used to monitor
the patient's level of pain.
c. the patient is informed about and has some control over the management of the pain.
d. a multimodal approach is used (e.g., sustained-release and short-acting opioids,
NSAIDs, adjuvant analgesics).
A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation
phase of burn recovery is
a. applying pressure garments.
b. repositioning the patient every 2 hours.
c. performing active ROM at least every 4 hours.
d. massaging the new tissue with water-based moisturizers. - Answer -a. applying
pressure garments.
A nurse is caring for a patient newly diagnosed with chronic inflammatory demyelinating
polyneuropathy (CIDP). Which statement can the nurse accurately use to teach the
patient about CIDP?
a. "Corticosteroids have little effect on this disease."
b. "Maintenance therapy will be needed to prevent relapse."
c. "You will go into remission in approximately eight weeks."
d. "You should be able to walk without help within three months." - Answer -b.
"Maintenance therapy will be needed to prevent relapse."
The nurse suspects an ankle sprain when a patient at the urgent care center describes
a. being hit by another soccer player during a game.
b. having ankle pain after sprinting around the track.
c. dropping a 10-lb weight on his lower leg at the health club.
d. twisting his ankle while running bases during a baseball game. - Answer -d. twisting
his ankle while running bases during a baseball game.
Which prevention strategy would the nurse include when teaching about home fire
safety?
a. Set hot water temperature at 140°F.
b. Use only hardwired smoke detectors.
c. Encourage regular home fire exit drills.
d. Do not allow older adults to cook unattended. - Answer -C. Encourage regular home
fire exit drills
The injury that is least likely to result in a full-thickness burn is
a. sunburn.
b. scald injury.
c. chemical burn.
d. electrical injury. - Answer -A. Sunburn
When assessing a patient with a partial-thickness burn, the nurse would expect to find
(select all that apply)
a. blisters.
b. exposed fascia.
c. exposed muscles.
d. intact nerve endings.
e. red, shiny, wet appearance. - Answer -a. blisters.
d. intact nerve endings.
e. red, shiny, wet appearance.
A patient is recovering from second- and third-degree burns over 30% of his body, and
the burn care team is planning for discharge. The first action the nurse should take
when meeting with the patient would be to
a. arrange a return-to-clinic appointment and prescription for pain medications.
b. teach the patient and the caregiver proper wound care to be performed at home.
c. review the patient's current health care status and readiness for discharge to home.
d. give the patient written information and websites for information for burn survivors. -
Answer -c. review the patient's current health care status and readiness for discharge to
home.
During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg
braces. Which level of injury does the nurse associate with this degree of recovery?
a. L1-2
b. T6-7
,c. T1-2
d. C7-8 - Answer -a. L1-2
A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous
system dysfunction. What would the nurse recognize as characteristic of this condition?
a. Tachycardia
b. Hypotension
c. Increased cardiac output
d. Peripheral vasoconstriction - Answer -b. Hypotension
A patient with spinal cord injury has severe neurologic deficits. What is the most likely
mechanism of injury for this patient?
a. Compression
b. Hyperextension
c. Flexion-rotation
d. Extension-rotation - Answer -c. Flexion-rotation
A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must
have the flu because he has a bad headache and nausea. The nurse's first priority is to
a. call the health care provider.
b. check the patient's temperature.
c. measure the patient's blood pressure.
d. elevate the head of the bed to 90 degrees. - Answer -c. measure the patient's blood
pressure.
The most common early symptom of a spinal cord tumor is
a. urinary incontinence.
b. back pain that worsens with activity.
c. paralysis below the level of involvement.
d. impaired sensation of pain, temperature, and light touch. - Answer -b. back pain that
worsens with activity.
During assessment of the patient with trigeminal neuralgia, the nurse should (select all
that apply)
a. inspect all aspects of the mouth and teeth.
b. assess the gag reflex and respiratory rate and depth.
c. lightly palpate the affected side of the face for edema.
d. test for temperature and sensation perception on the face.
e. ask the patient to describe factors that initiate an episode. - Answer -a. inspect all
aspects of the mouth and teeth.
d. test for temperature and sensation perception on the face.
,e. ask the patient to describe factors that initiate an episode.
During routine assessment of a patient with Guillain-Barré syndrome, the nurse finds
the patient is short of breath. The patient's respiratory distress is caused by
a. elevated protein levels in the CSF.
b. immobility resulting from ascending paralysis.
c. degeneration of motor neurons in the brainstem and spinal cord.
d. paralysis ascending to the nerves that stimulate the thoracic area. - Answer -d.
paralysis ascending to the nerves that stimulate the thoracic area.
A patient is admitted to the burn center with burns to his head, neck, and anterior and
posterior chest after an explosion in his garage. On assessment, the nurse auscultates
wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the
breath sounds are greatly decreased. Which action is the most appropriate for the nurse
to take next?
a. Encourage the patient to cough and auscultate the lungs again.
b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas.
c. Document the findings and continue to monitor the patient's breathing.
d. Anticipate the need for endotracheal intubation and notify the provider. - Answer -d.
Anticipate the need for endotracheal intubation and notify the provider.
Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury
include
a. adherence of albumin to vascular walls.
b. movement of potassium into the vascular space.
c. movement of sodium and water into the interstitial space.
d. hemolysis of red blood cells from large volumes of rapidly administered fluid. -
Answer -c. movement of sodium and water into the interstitial space.
To maintain a positive nitrogen balance in a major burn, the patient must
a. eat a high-protein, high-carbohydrate diet.
b. increase normal caloric intake by about four times.
c. eat at least 1500 calories/day in small, frequent meals.
d. eat a gluten-free diet for the chemical effect on nitrogen balance. - Answer -a. eat a
high-protein, high-carbohydrate diet.
A patient has 25% TBSA burn from a car fire. His wounds have been debrided and
covered with a silver-impregnated dressing. The nurse's priority intervention for wound
care would be to
a. reapply a new dressing without disturbing the wound bed.
b. observe the wound for signs of infection during dressing changes.
, c. apply cool compresses for pain relief in between dressing changes.
d. wash the wound aggressively with soap and water three times a day. - Answer -b.
observe the wound for signs of infection during dressing changes.
Pain management for the burn patient is most effective when (select all that apply)
a. a pain rating tool is used to monitor the patient's level of pain.
b. painful dressing changes are delayed until the patient's pain is completely relieved.
c. the patient is informed about and has some control over the management of the pain.
d. a multimodal approach is used (e.g., sustained-release and short-acting opioids,
NSAIDs, adjuvant analgesics).
e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the
rehabilitation phase of a burn injury. - Answer -a. a pain rating tool is used to monitor
the patient's level of pain.
c. the patient is informed about and has some control over the management of the pain.
d. a multimodal approach is used (e.g., sustained-release and short-acting opioids,
NSAIDs, adjuvant analgesics).
A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation
phase of burn recovery is
a. applying pressure garments.
b. repositioning the patient every 2 hours.
c. performing active ROM at least every 4 hours.
d. massaging the new tissue with water-based moisturizers. - Answer -a. applying
pressure garments.
A nurse is caring for a patient newly diagnosed with chronic inflammatory demyelinating
polyneuropathy (CIDP). Which statement can the nurse accurately use to teach the
patient about CIDP?
a. "Corticosteroids have little effect on this disease."
b. "Maintenance therapy will be needed to prevent relapse."
c. "You will go into remission in approximately eight weeks."
d. "You should be able to walk without help within three months." - Answer -b.
"Maintenance therapy will be needed to prevent relapse."
The nurse suspects an ankle sprain when a patient at the urgent care center describes
a. being hit by another soccer player during a game.
b. having ankle pain after sprinting around the track.
c. dropping a 10-lb weight on his lower leg at the health club.
d. twisting his ankle while running bases during a baseball game. - Answer -d. twisting
his ankle while running bases during a baseball game.
