NUR 425 final exam test map UPDATED ACTUAL Questions and CORRECT
Answers
includes teaching families to check water
temperatures, practice fire safety, and install
what health promotion education should smoke detectors.
the nurse provide to prevent burns?
supervise children near heat sources and store
chemicals safely.
history of injury (flame injury occurring in enclosed space)
clinical signs
- singed facial hair
what assessment findings indicate an - carbonaceous sputum (sputum with carbon particles that appear black)
inhalation injury? - burns on face/neck
- hoarseness, stridor
- respiratory distress
bronchoscopy = standard test for definitive diagnosis
superficial injuries that involve outermost layer of
skin (sunburn)
first-degree burns
involve entire epidermis & varying portions of the
dermis (painful with blisters)
second-degree burns
(full thickness)
third-degree burns
total destruction of the epidermis, dermis, and
underlying tissue, lack of sensation
, deep burn necrosis
fourth-degree burns
extends into deep tissue, muscle, or bone
used to estimate total body surface area (TBSA)
affected to guide fluid resuscitation.
quick method:
how does the nurse apply the rules of nine head and neck: 9%.
to determine the extent of burns present? each arm: 9%
each leg: 18%
front of torso: 18%
back of torso: 18%
perineum: 1%
remove the client from the chemical source.
brush off dry chemicals before irrigating.
irrigate with copious amounts of water for at least 20-30 minutes.
what emergent actions should the nurse
- patient is checked for contact lenses (removed immediately if in contact with eyes
implement for a chemical burn injury?
or facial burn)
remove contaminated clothing.
monitor airway, breathing, circulation (ABCs).
- prevent injury to rescuer
- stop injury – extinguish flames, cool the burn, irrigate chemical burns
how does the nurse prioritize care of a - ABCs – establish airway, breathing, & circulation
client with a burn injury during the - start oxygen & large-bore IVs
emergent/resuscitative phase to manage - remove restrictive objects & cover the wound
fluid resuscitation and prevent - do assessment surveying all body systems & obtain a history of the incident &
complications? pertinent patient history
- prevent hypothermia
- monitor urine output (0.5 mL/kg/hour)
- clean and debride wounds daily.
describe the collaborative and nursing - apply topical antimicrobials (e.g., silver sulfadiazine).
management of burn wound including skin - use temporary coverings (xenograft-pig, allograft-cadaver) or permanent
grafts and available options for wound (autograft-self).
closure - monitor for signs of infection.
- support nutrition for healing.
- encourage support group participation.
what considerations should the nurse
- provide psychological counseling.
implement to strengthen the client's coping
- promote independence in ADLs.
strategies during the postburn period of
- educate on long-term wound care and rehabilitation
care
- promoting positive body image
Hep A & E = fecal-oral route
what are the modes of transmission or
Hep B & C = blood borne
sources of infection for hepatitis?
Hep D = only people with hepatitis B are at risk
, - fatigue, anorexia, nausea, vomiting
what clinical manifestations would a client
- jaundice, dark urine, clay-colored stool
exhibit with acute hepatitis?
- RUQ tenderness
- rest and activity balance.
develop a plan of care to manage the - adequate nutrition and hydration.
symptoms of viral hepatitis. - avoid alcohol and hepatotoxic drugs.
- monitor liver function tests.
management =
- antiviral meds
direct-acting antivirals (e.g., ledipasvir, sofosbuvir).
- taken for several weeks.
- adherence is critical.
how is hepatitis C -regular liver function and viral load monitoring.
medically/pharmacologically managed? - lifestyle modifications to support liver health.
- alcohol potentiates disease (meds that effect the liver should be avoided)
- prevention! public health programs to decrease needle sharing among drug users
- screening of blood supply
- safety needles for health care workers
- avoid alcohol and hepatotoxic substances.
- eat a well-balanced diet.
what are discharge teaching needs for a
client with acute hepatitis?
- prevent transmission (hand hygiene, safe sex, avoid sharing needles)
- adhere to follow-up appointments.
definition criteria =
- neuro dysfunction
- PT/INR > 1.5
- no prior liver disease
what clinical manifestations would a client
exhibit with acute liver failure (ALF)?
clinical manifestations:
- rapid development of jaundice & hepatic encephalopathy
- profound anorexia
- affects other body systems (kidneys, CV system & neuro) ex. cerebral edema
treat underlying cause (e.g., acetaminophen overdose with NAC).
outline the care for clients with ALF manage complications (e.g., cerebral edema, infections).
including treatments for common causes
and managing complications associated monitor neurologic and coagulation status.
with this condition. monitor ICP
prepare for possible liver transplant.
administer lactulose to reduce ammonia levels.
what measures should be included in the
restrict dietary protein.
client's care with ALF who is experiencing
the later stages of hepatic
ensure safety (fall risk).
encephalopathy?
monitor neuro status frequently.
Answers
includes teaching families to check water
temperatures, practice fire safety, and install
what health promotion education should smoke detectors.
the nurse provide to prevent burns?
supervise children near heat sources and store
chemicals safely.
history of injury (flame injury occurring in enclosed space)
clinical signs
- singed facial hair
what assessment findings indicate an - carbonaceous sputum (sputum with carbon particles that appear black)
inhalation injury? - burns on face/neck
- hoarseness, stridor
- respiratory distress
bronchoscopy = standard test for definitive diagnosis
superficial injuries that involve outermost layer of
skin (sunburn)
first-degree burns
involve entire epidermis & varying portions of the
dermis (painful with blisters)
second-degree burns
(full thickness)
third-degree burns
total destruction of the epidermis, dermis, and
underlying tissue, lack of sensation
, deep burn necrosis
fourth-degree burns
extends into deep tissue, muscle, or bone
used to estimate total body surface area (TBSA)
affected to guide fluid resuscitation.
quick method:
how does the nurse apply the rules of nine head and neck: 9%.
to determine the extent of burns present? each arm: 9%
each leg: 18%
front of torso: 18%
back of torso: 18%
perineum: 1%
remove the client from the chemical source.
brush off dry chemicals before irrigating.
irrigate with copious amounts of water for at least 20-30 minutes.
what emergent actions should the nurse
- patient is checked for contact lenses (removed immediately if in contact with eyes
implement for a chemical burn injury?
or facial burn)
remove contaminated clothing.
monitor airway, breathing, circulation (ABCs).
- prevent injury to rescuer
- stop injury – extinguish flames, cool the burn, irrigate chemical burns
how does the nurse prioritize care of a - ABCs – establish airway, breathing, & circulation
client with a burn injury during the - start oxygen & large-bore IVs
emergent/resuscitative phase to manage - remove restrictive objects & cover the wound
fluid resuscitation and prevent - do assessment surveying all body systems & obtain a history of the incident &
complications? pertinent patient history
- prevent hypothermia
- monitor urine output (0.5 mL/kg/hour)
- clean and debride wounds daily.
describe the collaborative and nursing - apply topical antimicrobials (e.g., silver sulfadiazine).
management of burn wound including skin - use temporary coverings (xenograft-pig, allograft-cadaver) or permanent
grafts and available options for wound (autograft-self).
closure - monitor for signs of infection.
- support nutrition for healing.
- encourage support group participation.
what considerations should the nurse
- provide psychological counseling.
implement to strengthen the client's coping
- promote independence in ADLs.
strategies during the postburn period of
- educate on long-term wound care and rehabilitation
care
- promoting positive body image
Hep A & E = fecal-oral route
what are the modes of transmission or
Hep B & C = blood borne
sources of infection for hepatitis?
Hep D = only people with hepatitis B are at risk
, - fatigue, anorexia, nausea, vomiting
what clinical manifestations would a client
- jaundice, dark urine, clay-colored stool
exhibit with acute hepatitis?
- RUQ tenderness
- rest and activity balance.
develop a plan of care to manage the - adequate nutrition and hydration.
symptoms of viral hepatitis. - avoid alcohol and hepatotoxic drugs.
- monitor liver function tests.
management =
- antiviral meds
direct-acting antivirals (e.g., ledipasvir, sofosbuvir).
- taken for several weeks.
- adherence is critical.
how is hepatitis C -regular liver function and viral load monitoring.
medically/pharmacologically managed? - lifestyle modifications to support liver health.
- alcohol potentiates disease (meds that effect the liver should be avoided)
- prevention! public health programs to decrease needle sharing among drug users
- screening of blood supply
- safety needles for health care workers
- avoid alcohol and hepatotoxic substances.
- eat a well-balanced diet.
what are discharge teaching needs for a
client with acute hepatitis?
- prevent transmission (hand hygiene, safe sex, avoid sharing needles)
- adhere to follow-up appointments.
definition criteria =
- neuro dysfunction
- PT/INR > 1.5
- no prior liver disease
what clinical manifestations would a client
exhibit with acute liver failure (ALF)?
clinical manifestations:
- rapid development of jaundice & hepatic encephalopathy
- profound anorexia
- affects other body systems (kidneys, CV system & neuro) ex. cerebral edema
treat underlying cause (e.g., acetaminophen overdose with NAC).
outline the care for clients with ALF manage complications (e.g., cerebral edema, infections).
including treatments for common causes
and managing complications associated monitor neurologic and coagulation status.
with this condition. monitor ICP
prepare for possible liver transplant.
administer lactulose to reduce ammonia levels.
what measures should be included in the
restrict dietary protein.
client's care with ALF who is experiencing
the later stages of hepatic
ensure safety (fall risk).
encephalopathy?
monitor neuro status frequently.
