during the acute phase of burn the priority nursing intervention in caring for this client is
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Nursing Elites

ATI RN

ATI RN Nutrition Online Practice 2019

1. During the acute phase of a burn, the priority nursing intervention in caring for this client is:

Correct answer: D

Rationale: During the acute phase of a burn, fluid resuscitation is the priority nursing intervention. This phase is characterized by fluid loss and the risk of hypovolemic shock. Administering fluids is crucial to maintain perfusion and prevent complications such as organ failure. While prevention of infection, pain management, and prevention of bleeding are important aspects of burn care, fluid resuscitation takes precedence in the acute phase to stabilize the client's condition and prevent further damage.

2. Children with cerebral palsy, Down syndrome, and intellectual disabilities are likely to have abnormal sensory input and muscle tone. A small, underdeveloped tongue is common in many such disorders and results in diminished nutritional status.

Correct answer: C

Rationale: The first statement is true, but the second is false. These children often have a large tongue or tongue thrust, which can interfere with feeding and nutrition.

3. Angelo, An 8 month old child is brought to the health care facility with sunken eyes. You pinch his skin and it goes back very slowly. In what classification of dehydration will you categorize Angelo?

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

4. Maria’s statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” is an example of:

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. Which of the following should a patient with a history of chronic pancreatitis avoid?

Correct answer: D

Rationale: The correct answer is D: Alcohol. Alcohol consumption can exacerbate chronic pancreatitis due to its detrimental effects on the pancreas. Conversely, options A, B, and C: Low-fat dairy, Lean meats, and High-fiber vegetables, are generally recommended for patients with chronic pancreatitis. These dietary options are easier on the pancreas and less likely to provoke symptoms. Therefore, they are incorrect choices in this context.

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