Chapter 62: Management of Patients with Burn Injury; Hinkle: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Fourteenth Edition PREPU LEVEL 7

Specific potential complications are common to specific types of burns. Which burns can impair ventilation? a. face, neck, chest b. perineal c. hands, major joints d. legs

a. face, neck, chest Burns of the face, neck, or chest have the potential to impair ventilation due to their proximity to the areas where breathing occurs.

Which complication is common for victims of electrical burns? a. Inhalation injury b. Infection c. Cardiac dysrhythmia d. Hypovolemic shock

c. Cardiac dysrhythmia Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? a. Mederma b. Integra c. Transcyte d. Biobrane

d. Biobrane Biobrane is a nylon-silicone membrane coated with a protein. Mederma is a topical gel that can reduce scarring. Integra consists of a two-layer membrane: one is a synthetic epidermal layer , and the other contains cross-linked collagen fibers that mimic the dermal layer of skin. Transcyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable membrane attached to nylon mesh.

In a client with burns on the legs, which nursing intervention helps prevent contractures? a. Applying knee splints b. Elevating the foot of the bed c. Hyperextending the client's palms d. Performing shoulder range-of-motion exercises

a. Applying knee splints Applying knee splints is one method which can help prevent leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs which is the focus for this individual's treatment and care.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? a. BUN: 28 mg/dL b. K+: 5.0 mEq/L c. Na+: 145 mEq/L d. Ca: 9 mg/dL

a. BUN: 28 mg/dL The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

Burn shock is characterized by which of the following? a. Capillary leak b. Severe hypervolemia c. Organ hyperperfusion d. Elevated blood pressure (BP)

a. Capillary leak Burn shock is characterized by capillary leak, "third spacing" of fluid, severe hypovolemia, and decreased cardiac output (CO). Progressive edema develops in unburned tissue and organs, causing hypoperfusion and hypovolemic shock. As fluid loss continues and vascular volume decreases, the CO and BP falls. This is the onset of burn shock.

The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? a. Electrical burns usually follow an internal path. b. Lightning is higher in voltage than electricity. c. The skin is a good conductor of electricity. d. Moisture intensifies the damage inflicted.

a. Electrical burns usually follow an internal path. Electrical current follows the path of less resistance. Because the skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current.

Which type of burn injury requires skin grafting? a. Full-thickness b. Superficial c. Superficial partial-thickness d. Deep partial-thickness

a. Full-thickness A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? a. Full-thickness b. Superficial c. Superficial partial-thickness d. Deep partial-thickness

a. Full-thickness A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? a. Diverticulitis b. Hematemesis c. Paralytic ileus d. Ulcerative colitis

c. Paralytic ileus Patients who are critically ill, including those with burns, are predisposed to altered gastrointestinal (GI) motility for many reasons, which may include impaired enteric nerve and smooth muscle function, inflammation, surgery, medications, and impaired tissue perfusion. Three of the most common GI alterations in burn-injured patients are paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and translocation of bacteria. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? a. The wound will take up to 3 weeks to heal. b. Pain management will be a challenge. c. Skin grafting will be necessary. d. Ligaments, tendons, muscles, and bone are not involved.

c. Skin grafting will be necessary. In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? a. Cerium nitrate solution b. Gentamicin sulfate c. Sulfadiazine, silver (Silvadene) d. Mafenide (Sulfamylon)

c. Sulfadiazine, silver (Silvadene) With use of silver sulfadiazine (Silvadene), the nurse should watch for leukopenia 2 to 3 days after initiation of therapy. (Leukopenia usually resolves within 2 to 3 days.)

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? a. 9% b. 18% c. 27% d. 36%

d. 36% According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area.

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? a. 18% b. 27% c. 30% d. 36%

d. 36% The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? a. Complaints of intense thirst b. Moderate to severe pain c. Urine output of 70 ml the first hour d. Hoarseness of the voice

d. Hoarseness of the voice Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? a. Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. b. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. c. Remove his burned pants so that the air can help cool the wound. d. Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area.

a. Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: a. Hyperkalemia. b. Hypernatremia. c. Hypocalcemia. d. Hypoglycemia.

a. Hyperkalemia. Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

Which of the following is to be expected soon after a major burn? Select all that apply. a. Hypotension b. Tachycardia c. Anxiety d. Hypertension e. Bradycardia

a. Hypotension b. Tachycardia c. Anxiety Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

Which of the following site is the source of most microbes leading to bacterial infection? a. Intestinal tract b. Respiratory tract c. Skin d. Mucous membranes

a. Intestinal tract When the wound is healing, it must be protected from infection. A primary source of bacterial infection is the patient's intestinal tract, the source of most microbes. The respiratory tract, skin, and mucous membranes are not the source of most microbes.

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? a. Mechanical b. Surgical c. Natural d. Chemical

a. Mechanical Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic debridement agents are available to promote debridement of the burn wounds. With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tissue.

Which of the following is the analgesic of choice for burn pain? a. Morphine sulfate b. Fentanyl c. Demerol d. Tylenol with codeine

a. Morphine sulfate Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply. a. Place the client in a horizontal position. b. Roll the client in a blanket to smother the fire. c. Place the client in a vertical position. d. Open a door and encourage air in an enclosed space.

a. Place the client in a horizontal position. b. Roll the client in a blanket to smother the fire. If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.

Following a burn injury, the nurse determines which area is the priority for nursing assessment? a. Pulmonary system b. Cardiovascular system c. Pain d. Nutrition

a. Pulmonary system Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? a. Reduction in blood volume b. Sodium excess c. Potassium deficit d. Increased urinary output

a. Reduction in blood volume A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.

A nurse is providing discharge teaching for a client with a burn wound on the leg. What instructions are important to give the client? Select all that apply. a. Report increased redness and wound drainage to the healthcare provider. b. Apply lubricating lotion to the wound bed. c. Wash the wound with soap and water. d. Continue physical therapy exercises. e. Take pain medications daily.

a. Report increased redness and wound drainage to the healthcare provider. c. Wash the wound with soap and water. d. Continue physical therapy exercises. The client being discharged with burn wound care needs to demonstrate wound care technique; take prescribed pain medications if needed 30 minutes prior to wound care to achieve maximum effectiveness; use mild soap, water, and a clean washcloth to clean wounds; apply prescribed topical medications( not lubricating lotions to the wound bed) and dressings as instructed; inspect wounds carefully with each dressing change for signs of infection, including increased redness, swelling, drainage, or foul odor; and state aspects of activities of daily living as per therapy.

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? a. Risk for Impaired Gas Exchange b. Acute Pain c. Infection Risk d. Altered Tissue Perfusion

a. Risk for Impaired Gas Exchange During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? a. To prevent collapse and further injuries b. To keep fire and smoke from airway c. To extinguish flames more quickly d. To promote blood flow to the brain and vital organs

b. To keep fire and smoke from airway The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. The stop, drop, and roll method is a quick and efficient means to extinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? a. 9% b. 18% c. 27% d. 36%

c. 27% According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

Which zone of burn injury sustains the most damage? a. Outer b. Middle c. Inner d. Protective

c. Inner Each burned area has three zones of injury. The inner area (known as the zone of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? a. Albumin b. Dextrose 5% in water (D5W) c. Lactated Ringer's solution d. Normal saline solution with 20 mEq of potassium per 1,000 ml

c. Lactated Ringer's solution Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours? a. 90 g/day b. 110 g/day c. 180 g/day d. 270 g/day

180 g/day Recommendations from recent literature advocate protein requirements of 1.5 to 2 g/kg/day (Saffle, Graves, & Cochran, 2012).

Which of the following measures can be used to cool a burn? a. Application of cool water b. Application of ice directly to burn c. Wrapping the person in ice d. Using cold soaks or dressings for at least 1 hour

a. Application of cool water Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? a. Music therapy may provide reality orientation, distraction, and sensory stimulation. b. Music therapy diverts the client's attention toward painful stimulus. c. Humor therapy has not proven effective in the management of burn pain. d. Pet therapy has proven effective in the management of burn pain.

a. Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the client's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It allows for client self-expression. Humor therapy has proven effective in the management of burn pain. Pet therapy has not proven effective in the management of burn pain.

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? a. Superficial partial thickness b. Deep partial-thickness c. Full-thickness d. Fourth degree

b. Deep partial-thickness A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis as well as injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.

A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? a. Autografts b. Heterografts c. Homografts d. Xenografts

c. Homografts Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). An autograft uses the client's own skin, which is transplanted from one part of the body to another.

A child tips a pot of boiling water onto his bare legs. The mother should: a. Avoid touching the burned skin and take the child to the nearest emergency department. b. Cover the child's legs with ice cubes secured with a towel. c. Immerse the child's legs in cool water. d. Liberally apply butter or shortening to the burned areas.

c. Immerse the child's legs in cool water. The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage.

A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested? a. Face only b. Face, neck, and chest c. Face and neck d. Neck and chest

d. Neck and chest Skin grafting is essential for deep partial-thickness burns on the client's neck and chest because the skin layers responsible for regeneration have been destroyed. The client's face does not need skin grafting because the burns are superficial and will heal unassisted.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? a. Roll the client in a blanket. b. Cover the client with a wet cloth. c. Place the client with the head positioned slightly below the rest of the body. d. Avoid immediate IV fluid therapy.

a. Roll the client in a blanket. When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? a. Superficial b. Full-thickness c. Superficial partial-thickness d. Deep partial-thickness

a. Superficial A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

The open method (exposure method) of burn care, which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale however. On which areas of the body are burns still being treated this way? Select all that apply. a. The face b. The perineum c. The chest d. The legs

a. The face b. The perineum The open method is still being used with the face and the perineum.

As the first priority of care, a patient with a burn injury will initially need: a. a patent airway established. b. an indwelling catheter inserted. c. fluids replaced. d. pain medication administered.

a. a patent airway established. Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen.

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? a. escharotomy b. debridement c. allograft d. silvadene application

a. escharotomy Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? a. inflammatory b. neuroendocrine c. intravascular fluid excess d. hypertension

a. inflammatory The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

Which antimicrobials is not commonly used to treat burns? a. tetracycline b. silver sulfadiazine (Silvadene) c. mafenide (Sulfamylon) d. silver nitrate (AgNO3) 0.5% solution

a. tetracycline Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? a. 1,200 mL b. 2,400 mL c. 3,600 mL d. 4,800 mL

b. 2,400 mL The ABA consensus formula provides for the volume of an isotonic solution (e.g., lactated Ringer's [LR]) to be administered during the first 24 hours in a range of 2 mL/kg/percentage TBSA. Half of the calculated total should be given over the first 8 postburn hours, and the other half should be given over the next 16 hours. Thus, the equation to find the minimum amount to infuse for this scenario is as follows: 2 mL × 80 kg × 30 = 4,800 mL of solution to be administered in the first 24 hours, with half this amount, 2,400 mL, to be administered in the first 8 hours.

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? a. A urinary output of 10 mL/hr b. A urinary output of 30 mL/hr c. A urinary output of 80 mL/hr d. A urinary output of 100 mL/hr

b. A urinary output of 30 mL/hr For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client a. Prevent infection b. Fluid resuscitation c. Endotracheal tube placement d. Strict intake and output

b. Fluid resuscitation Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? a. Anemia b. Gastric ulcers c. Hyperthyroidism d. Cardiac arrest

b. Gastric ulcers The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool? a. Rule of nines b. Lund and Browder method c. Hand method d. Parkland formula method

b. Lund and Browder method The Lund and Browder method divides the body into smaller segments. Different percentages are assigned to body parts, depending on patient's age. For example, the adult head is equivalent to 9%,whereas the infant head is 19%. This method is more accurate when dealing with children. The rule of nines and hand method are quick assessment techniques for estimating burns. The Parkland formula incorporates fluid resuscitation requirements for burns.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? a. Mechanical b. Natural c. Enzymatic d. Surgical

b. Natural Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.

The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality? a. Administer intravenous antibiotics b. Remove burned tissue c. Regular bathing of burned areas d. Provide intravenous fluid therapy

b. Remove burned tissue The acute/intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of body functions. One of the most important medical interventions for clients with burns that positively affect mortality is early excision (surgical removal of tissue). The presence of open wounds or invasive organisms triggers the response to a large burn injury, a systemic cascade of events. Excising the necrotic tissue can ameliorate this response and preserve underlying viable tissue. Intravenous antibiotics and intravenous fluid therapy are not identified as interventions to reduce the risk of mortality. Regular bathing of unburned areas and changing linens can help prevent infection, but burned areas are not bathed.

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? a. The client is in hypovolemic shock. b. The client has experienced extensive full-thickness burns. c. The paramedic administered high doses of opioids during transport. d. The client has experienced partial-thickness burns.

b. The client has experienced extensive full-thickness burns. In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? a. The client's heart rate is rapid and regular. b. The client's urinary output is 0.5 to 1 mL/kg/hour. c. The client's breathing is unlabored, and skin is clammy. d. The client is alert and conscious.

b. The client's urinary output is 0.5 to 1 mL/kg/hour. Successful fluid resuscitation is gauged by a urinary output of 0.5 to 1 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury? a. Hypernatremia b. Hypokalemia c. Hyperkalemia d. Hypercalcemia

d. Hyperkalemia Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. During burn shock, serum sodium levels vary in response to fluid resuscitation. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. Hyponatremia may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space.

A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care? a. The client's serum sodium levels are elevated. b. The client exhibits metabolic alkalosis. c. The client's urinary output has fallen below 30 ml/hour. d. The client's complete blood count readings reflect a reduced hematocrit.

d. The client's complete blood count readings reflect a reduced hematocrit. During the intermediate phase of burn care, the client's hematocrit should diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues. In the intermediate phase of burn care, the client will experience serum sodium deficits. Urinary output increases during this phase as renal perfusion increases. Loss of serum sodium leads to metabolic acidosis, not metabolic alkalosis.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to a. increase metabolic rate. b. increase glucose demands. c. increase skeletal muscle breakdown. d. decrease catabolism.

d. decrease catabolism. The most important intervention in the nutritional support of a client 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%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: a. fluid resuscitation. b. infection. c. body image. d. pain management.

d. pain management. With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.