week 5 (burn)
A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client? Slow heart rate Kidney stones and blood clots Imbalance in electrolytes Elevated central venous pressure (CVP)
Correct response: Kidney stones and blood clots Explanation: Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated hematocrit levels and blood cell counts indicate hemoconcentration, which means a high ratio of blood components in relation to watery plasma. This increases the potential for blood clots and urinary stones. In hypovolemia, the heart rate tends to be high as the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte levels tend to remain normal because they are depleted in proportion to the water loss. CVP is usually below 4 cm H2O.
The nurse is monitoring the intake and output of a client with deep partial-thickness or second-degree burns. The child weighs 75 lb (34 kg). The nurse will contact the physician if the child's urine output drops below how many milliliters per hour? (Round you answer to the nearest whole number.)
Correct response: 34 Explanation: The child with burns should have a urine output of at least at least 1 mL/kg/hour. The calculations for this scenario are: 1 mL X 34 kg= 34 mL/hour
The nurse on the burn unit is caring for an adolescent with burns to the face and anterior neck, anterior chest, bilateral arms circumferentially, and the right anterior leg. Based on the Rule of Nines, calculate the body surface area that is burned. Record your answer using one decimal place. Rule of Nines Surface areaAnterior head 4.5%Posterior head 4.5%Anterior torso 18%Posterior torso 18%Anterior leg, each 9%Posterior leg, each 9%Anterior arm, each 4.5%Posterior arm, each 4.5%Genitalia/perineum 1%
Correct response: 49.5 Explanation: The Rule of Nines is the standard for estimating total body surface area burned. To calculate: anterior head = 4.5% anterior chest (torso) = 18% both arms anterior and posterior - 9% each = 18% anterior right leg = 9% Total = 49.5%
The nurse is preparing an assessment guide for the emergency department staff regarding assessment of clients are admitted with burn injuries. What should the nurse be sure to include in the assessment guide for primary emergency assessment of burns? Airway assessment Depth of the burn/s Presence of edema Percentage of body burned Pulse strength
Correct response: Airway assessment Presence of edema Pulse strength Explanation: Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, p. 1762.
The emergency nurse is performing an assessment on a client who experienced second and third degree burns of the arms and hands from a kitchen grease fire. Which assessment should be performed first? Details of the incident. Breathing status and lung sounds. Extensiveness and depth of the burns. Blood pressure and heart rate
Correct response: Blood pressure and heart rate Explanation: When a client is burned, breathing should be the first concern if the client may have experienced an inhalation injury. Since this client did not, circulation and perfusion become the greatest concern which are assessed with blood pressure and heart rate. Skin assessment of the burns is important after circulation is stabilized. Information about the detail of the incident are not a priority.
The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. Vomiting Burns Diarrhea Dehydration Trauma
Correct response: Burns Dehydration Explanation: The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.
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? Rule of nines Lund and Browder method Hand method Parkland formula method
Correct response: Lund and Browder method Explanation: 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.
A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns? deep tissue cooling continuing inflammatory process protein cell coagulation All options are correct.
Correct response: deep tissue cooling Explanation: Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-3, p. 1850.
A client has experienced first degree burns due to sun exposure and states, "The itchiness is so bad, but I don't want to scratch because it hurts." What should the nurse recommend? Select all that apply. A warm bath An oral antihistamine An occlusive cream An emollient lotion Sunscreen with SPF 30 or higher
An oral antihistamine An emollient lotion Explanation: After experiencing a burn, many people experience severe pruritus. To manage this, an antihistamine and emollient are recommended. A warm bath could exacerbate the pruritus. An occlusive would not be helpful for this skin condition as it would not reduce pruritus, is impractical, and uncomfortable for the client. Using sunscreen now would only be recommended if the client were planning on being exposed to sunlight; the sunscreen would not reduce the pruritus.
When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? Deep partial thickness Superficial partial thickness Full thickness Superficial
Correct response: Deep partial thickness Explanation: A deep, partial-thickness burn is similar to a second-degree burn and is associated with scalds and flash flames. Superficial partial thickness burns are similar to first-degree burns and are associated with sunburns. Full thickness burns are similar to third-degree burns and are associated with direct flame, electric current, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.
Following a severe sunburn that resulted in second-degree burns with multiple blisters, the skin team nurse notices that after several weeks of treatment, the skin appears to be regenerating. The nurse contributes this to which structure of the skin? Keratinocytes Basement membrane zone Merkel cells Langerhans cells
Correct response: Merkel cells Explanation: Merkel cells are epidermal cells that function in cutaneous sensation. Merkel cells display distinctive, dense granules in their organelles and cytoplasm, suggesting that they possess neurosecretory function. These functions may include metabolic support of their associated neurons, neuron development, and regeneration after injury. The basement membrane zone is an interface between the dermis and epidermis. The keratinocytes are the predominant cell type of the epidermis. They produce a fibrous protein called keratin, which is essential to the protective function of skin and may be involved in the immune system. Langerhans cells are dendritic cells that reside principally in the stratum spinosum of the epidermis and play a major role in the functioning of the skin's immune system.
The client comes to the emergency department with skin burns and tells the practitioner that they were caused by a diathermy treatment. The practitioner understands that the burns were caused by which type of radiation injury? Ultraviolet radiation Non-ionizing radiation Ionizing radiation Electrical currents
Correct response: Non-ionizing radiation Explanation: Low-frequency non-ionizing radiation is used widely in radar, television, industrial operations, household appliances, and medical applications (e.g., diathermy).
The nurse is assessing an 80-year-old client who has scald burns on both hands and forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first? Clean the wounds with warm water. Apply antibiotic cream. Refer the client to a burn center. Cover the burns with a sterile dressing.
Correct response: Refer the client to a burn center. Explanation: The nurse should have the client transported to a burn center. The client's age and the extent of the burns require care by a burn team and the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.
A parent of a toddler brings the child to the emergency department because the child has accidentally been scalded by hot water spilling from the stove. In order to differentiate the burn from potential abuse, the nurse first should assess the child: on the back of the body. on the front of the body. for a circular pattern. on the buttocks.
Correct response: on the front of the body. Explanation: Accidental scaldings are usually splash-related and occur on the front of the body. Any burns on the back of the body or in a well-defined circular or glove pattern may indicate physical abuse. Immersion burns on the buttocks are also suspicious injuries.
Following an explosion at a chemical plant, a nurse is triaging clients. One client has a penetrating abdominal wound from a piece of shrapnel. What color coordinate would the nurse assign to this client? yellow red green black
Correct response: yellow Explanation: A yellow triage tag means the client is in serious condition yet stable enough to survive if treatment is delayed 6 to 8 hours. Red tags are assigned to life-threatening injuries that require immediate medical attention. Green tags indicate the client has minor injuries, such as minor lacerations or superficial burns. Black tags indicate the client is going to die soon and usually apply to serious head injuries or multisystem traumas.
A client who has severe thermal burns and is on mechanical ventilation becomes delusional and attempts to remove the tubes. The nurse gives the client propofol, a sedative. As a result, it's most important that the client receive a supplementation of zinc. sodium. potassium. magnesium.
Correct response: zinc. Explanation: Propofol causes urinary zinc losses. Clients with burns are particularly susceptible to zinc deficiency; therefore, this client may need zinc supplementation. Burn clients are prone to electrolyte imbalances, including elevated or depressed sodium and potassium levels; however, these aren't specifically related to propofol therapy. The client may need magnesium supplementation, but not as a result of propofol therapy.
