which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?

A. high protein
B. high carbohydrate
C. low carbohydrate
D. low protein

Correct answer: A

Rationale: Clients with major burns are in a hypermetabolic state, leading to increased protein catabolism. Therefore, a high-protein diet is essential to help them maintain a positive nitrogen balance and support wound healing. High carbohydrate diets do not directly contribute to achieving a positive nitrogen balance, making choice B incorrect. Similarly, low carbohydrate diets are not recommended for clients with major burns as carbohydrates provide essential energy needed for healing. Low protein diets are contraindicated for clients with major burns as they require higher protein intake to support tissue repair and prevent further breakdown.

2. What is distraction therapy?

A. Focusing one's attention on stimuli other than pain.
B. Cognitive reappraisal.
C. The replacement of positive images of pain with other images.
D. The use of medication and meditation.

Correct answer: A

Rationale: Distraction therapy involves directing attention away from pain towards positive stimuli, which can help reduce the perception of pain. Choice A is the correct answer as it accurately defines distraction therapy. Cognitive reappraisal (Choice B) involves changing the way one thinks about a situation to alter its emotional impact, which is different from distraction therapy. Choice C is incorrect because distraction therapy does not involve replacing images of pain with other images, but rather focusing on something unrelated. Choice D is incorrect as distraction therapy does not necessarily involve medication or meditation, but rather the redirection of attention.

3. The nurse is caring for a client awaiting test results on a biopsy. The client is unconscious, and the physician informs the client's spouse that the biopsy came back positive for cancer. The spouse asks the nurse if they will not share this news with the client because they would prefer the client be unaware of the diagnosis. Which of the following responses is most appropriate?

A. "I will have a psychiatrist confirm whether the news will cause negative effects, and if so, I will comply with your request."?
B. "For ethical reasons, I am unable to withhold this information from the client."?
C. "You do not have the option to sign paperwork stating you are accepting the risk of not sharing this with the client."?
D. "You must have a durable power of attorney for healthcare advanced directive in place before I can consider this request."?

Correct answer: B

Rationale: The correct response is, "For ethical reasons, I am unable to withhold this information from the client."? The ethical principle of veracity requires that the nurse is truthful with the client and does not withhold information even if it is requested by the family. Choice A is incorrect because seeking a psychiatrist's confirmation is not necessary to uphold the ethical principle of truth-telling. Choice C is incorrect as implying that signing paperwork overrides the nurse's ethical obligation to be honest with the client is inappropriate. Choice D is also incorrect as a durable power of attorney is not relevant in this situation where the spouse is asking the nurse to withhold information.

4. A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?

A. "Because it gives you comfort, you may wear it."?
B. "It is a violation of religious rights to forbid it."?
C. "I am sorry, but it is not safe for you to wear the crucifix during this test."?
D. "You may wear it because it is important to you."?

Correct answer: C

Rationale: No metal objects may be worn while receiving magnetic resonance imaging due to safety risks involved with the strong magnet. The correct response by the nurse should prioritize the safety of the client. Allowing the client to wear the metal crucifix poses a risk of injury or interference with the imaging process. Option A is not appropriate as safety takes precedence over comfort in this situation. Option B is incorrect as it does not address the safety concerns associated with wearing metal objects during an MRI. Option D is also incorrect as it fails to acknowledge the safety issue involved and instead focuses solely on the importance to the client. It is important for the nurse to offer alternative forms of spiritual support that do not pose a risk during the MRI procedure.

5. Which is the proper hand position for performing chest vibration?

A. cup the hands
B. use the side of the hands
C. flatten the hands
D. spread the fingers of both hands

Correct answer: C

Rationale: The correct hand position for performing chest vibration is to flatten the hands. By flattening the hands over the area of the body where chest percussion is applied, vibrations can be conducted effectively to the chest to help loosen secretions. Cupping the hands may dampen vibrations, using the side of the hands reduces the surface area in contact with the chest, and spreading the fingers can lead to uneven pressure distribution. Therefore, flattening the hands provides the necessary contact and surface area to perform chest vibration efficiently.