N436 Inflammation, Wound Healing, SCI, Burn Q's

b. The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment, the nurse would expect to find which of the following symptoms? A. Blisters B. Reddening of the skin C. Destruction of all skin layers D. Damage to sebaceous glands

b. silver sulfadiazine is a metallic type of antiseptic that is widely used on burns. The silver in the solution is toxic to bacteria, and prevents them from reproducing.

The nurse should expect to apply which type of ordered antiseptic to a client with a burn wound, once the area has been cleansed with sterile saline? a. copper containing b. silver containing c. biguanide d. acetic acid

b.

When caring for a client with extensive burns, the nurse anticipates that pain medication will be administered via which route? a. oral b. IV c. IM d. Subq

a. in early burn care, the client's greatest need has to do with fluid resuscitation because of large volume fluid loss through the damaged skin.

A client is admitted to a burn intensive care unit with extensive full thickness burns. What should be the nurse's initial concern? a. fluid status b. risk for infection c. body image d. level of pain

c. a universal concern in the care of donor sites for burn care is to keep the site away from sources of pressure.

A nurse is caring for a client with a new donor site that was harvested to treat a burn. The nurse should position the client to: a. allow ventilation of the site b. make the site dependent c. avoid pressure on the site d. keep the site fully covered

c. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which of the following recommendations? A. The total 24-hour fluid requirement should be administered in the first 8 hours. B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. C. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. D. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

a, c. Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, and cherry red skin color

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which of the following assessment findings would alert you to the presence of an inhalation injury (select all that apply)? A.Singed nasal hair B.Generalized pallor C.Painful swallowing D.Burns on the upper extremities E.History of being involved in a large fire

a. the pt is likely to have suffered a smoke inhalation injury because thermal burns are caused by flames that emit smoke and because the pt is unconscious.

A pt in the emergent phase of burn care for thermal burns on 20% of the total body surface area is unconscious. Which assessment data is the most important for the nurse's evaluation of the pt's injuries? a. condition of the oropharynx b. percentage of TBSA affected c. location of the pt in the fire d. comorbidities of the pt

1. A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, calculate the total calories the patient should receive each day. ____________________

ANS: 2140 DIF: Cognitive Level: Application REF: 190 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

c. A full thickness burn involves all skin layers, including the epidermis and dermis, and may extend into the subcutaneous tissue and fat.

A client with burn injury asks the nurse what the term full thickness means. The nurse should respond that burns classified as full thickness involve tissue destruction down to which level? a. epidermis b. dermis c. subcutaneous tissue d. internal organs

a. Mafenide is useful in treatment of partial and full thickness burns to prevent septicemia caused by organisms suche as pseudomonas aeruginosa.

A client's burn is infected and mafenide (Sulfamylon) is prescribed. The nurse's knowledge about this medication would indicate that which organism is involved? a. pseudomonas aeruginosa b. tubercle bacillus c. Methicillin resistant staphylococcus aureus (MRSA) d. Candida albicans

a. The pt's potassium level puts them at risk for life threatening cardiac dysrhythmias.

A male burn pt who was struck by lightning arrives at the emergency department with full thickness burns to the arms and chest and with a cervical collar in place. Which assessment finding is the nurse's priority? a. serum K+ of 5.6 mEq/L b. Arterial blood ph of 7.35 c. Cervical spine fracture d. hemoglobin 18g/dL

d. assessing the pt's chest expansion is initially the most important because a sever burn that includes the anterior and posterior thorax can restrict chest expansion from eschar or scar tissue.

A male pt suffered full thickness burns to the chest and back and the nurse notes the pressure alarm on his mechanical ventilator is sounding every 5 minutes. What is the most relevant assessment to prevent respiratory complications in this pt? a. pH b. PaCO2 c. Breath sounds d. chest expansion

d. wash the wound aggressively with soap and water three times each day. Infection is the most serious threat for further tissue injury and possible sepsis.

A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. Your priority intervention for wound care is to: a. reapply a new dressing without disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief in between dressing changes d. wash the wound aggressively with soap and water three times each day.

d. If any healed areas break open, I should cover them with a sterile dressing and then immediately report it."

A patient has been treated for second- and third-degree burns over 30% of his body and is now ready for discharge. You provide discharge instructions related to wound care. Which statement indicates that the patient understands the instructions? a. I can expect occasional periods of low grade fever and can take Tylenol every 4 hours b. I must wear my jobst elastic garment all day and can only remove it when I'm going to bed. c. I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water. d. If any healed areas break open, I should cover them with a sterile dressing and then immediately report it."

d. Anticipate the need for endotracheal intubation, and notify the physician. Inhalation injury results in exposure of respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. You should anticipate the need for intubation.

A patient is admitted to the burn center with burns over his head, neck, chest, back, and left arm and hand after an explosion and fire in his garage. On admission to the unit, you auscultate wheezes throughout the lung fields. On reassessment, you notice that the wheezes are gone and the breath sounds are greatly diminished. Which of the following actions is the most appropriate next step? a. place the pt in high fowler's position b. encourage the pt to cough and auscultate the lungs again c. document the results and continue to monitor the pt's progress d. anticipate the need for endotracheal intubation and notify the physician

c. Using the rule of nines, the face and neck together encompass 4.5% of the body area; the right upper arm encompasses 9% of the body area; and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together, the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

A patient is admitted with first- and second-degree burns covering the face, neck, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, the nurse would calculate the extent of these burns as being A. 9%. B. 18%. C. 22.5%. D. 36%.

c Rationale: Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a person with limited available skin for harvesting. CEA is grown from biopsy specimens obtained from the patient's own unburned skin.

A patient is to undergo skin grafting with the use of cultured epithelial autografts full-thickness burns. The nurse explains to the patient that this treatment involves a) Shaving a split-thickness layer of the patient's skin to cover the burn wound. b) Using epidermal growth factor to cultivate cadaver skin for temporary wound coverage. c) Growing small specimens of the patient's skin into sheets to use as permanent skin coverage. d) Exposing animal skin to growth factors to decrease antigenicity so it can be used for permanent wound coverage.

d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.

A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? a) "Blood loss from burned tissue is the most likely cause of hypovolemia." b) "Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia." c) "The usual cause of hypovolemia is vaporation of fluid from denuded body surfaces." d) "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

b. albuterol stimulates beta adrenergic receptors in the lungs to cause bronchodilation and is nonselective and also causes receptors in the heart to increase heart rate.

A pt who has an inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? a. gi distress b. tachycardia c. restlessness d. hypokalemia

a. applying pressure garments. Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitative phase of burn recovery is: a. applying pressure garments. b. repositioning the pt every 2 hours c. performing active ROM at least every 4 hours d. massaging the new tissue with water based moisturizers

36 The anterior and posterior portions of one leg are 18%, if both legs are burned, the total is 36%.

A triage nurse in the ED admits a 50 year old male client with second degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of his body is burned? Record your answer using a whole number.

d. The nurse must know where the accident occurred to determine if the pt was rescued from an enclosed space. If so, the pt is at high risk for an inhalation injury because the enclosure concentrates the noxious fumes making an inhalation injury more likely.

A victim of an industrial accident has chemical spilled on his face and body. The chemical, which has a pH of 7.51, is flushed with water by paramedics. What is the most important information for the receiving nurse to obtain about the pt from the paramedics? a. containment of chemical b. duration of water flushing c. other injuries of the victim d. specific location of accident

2. A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Sponge patient with cool water. b. Administer intravenous antibiotics. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

ANS: B, D, A, C The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last. DIF: Cognitive Level: Analysis REF: 190 | 199 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

18. A diabetic patient is admitted for a laparotomy and possible release of adhesions. When planning interventions to promote wound healing, the nurse's highest priority will be a. maintaining the patient's blood glucose within a normal range. b. ensuring that the patient has an adequate dietary protein intake. c. giving antipyretics to keep the temperature less than 102° F (38.9° C). d. redressing the surgical incision with a dry, sterile dressing twice daily.

ANS: A Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition also is important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing.

11. Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a patient's stage III sacral pressure ulcer? a. Administer the ordered PRN oral opioid 30 minutes before the dressing change. b. Soak the old dressings with sterile saline a few minutes before removing them. c. Pour sterile saline onto the new dry dressings after the wound has been packed. d. Apply antimicrobial ointment before repacking the wound with moist dressings.

ANS: A Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.

13. A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Remove the patient's shoe and sock. c. Apply a warm moist pack to the ankle. d. Assess the ankle's range of motion (ROM).

ANS: A Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The soccer shoe does not need to be removed immediately and will help to compress the injury if it is left in place.

a.

The injury that is least likely to result in a full thickness burn is: a. sunburn b. scald injury c. chemical burn d. electrical injury

b. successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses and clear sensorium.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which of the following would provide the most reliable indicator for determining the adequacy? a. vital signs b. urine output c. mental status d. peripheral pulses

c. autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3-7 days. this period allows the autograft time to adhere to the wound bed.

The nurse is caring for a client following an autograft and grafting to a burn would on the right knee. Which of the following would the nurse anticipate to be prescribed for the client? a. out of bed b. brp c. Immobilization of the affected leg d. placing the affected leg in a dependent position

b. 11-20% - signs include flushing, headache, decreased visual acuity, decreased cerebral functioning, and slight breathlessness. 21-40% - signs include nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia; levels of 41-60% result in seizure and come and levels higher than 60% result in death

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate which of the following signs in the client? a. coma b. flushing c. dizziness d. tachycardia

d. during the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shift.

The nurse is caring for a client who sustained superficial partial thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the resuscitation/emergent phase of the burn injury? a. decreased heart rate b. increased urinary output c. increased blood pressure d. elevated hematocrit levels

d. A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increases gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, the nurse should implement which of the following dietary choices? A. Full liquids only B. Whatever the patient requests C. High-protein and low-sodium foods D. High-calorie and high-protein foods

a, c, d, e. An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion. Pain control is essential in the care of a patient with a burn injury

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which of the following interventions would the nurse expect to include in this patient's care (select all that apply)? A.Escharotomy B.Administration of diuretics C.IV and oral pain medications D.Daily cleansing and debridement E.Application of topical antimicrobial agent

a. Escharotomies arepreformed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third degree burn.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third degree circumferential arm burn. The nurse understands that the anticipated therapeutic outcome of the escharotomy is: a. return of distal pulses b. brisk bleeding from the site c. decreasing edema formation d. formation of granulation tissue

c. ppe should be worn whenever entering the client's room

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique? a. using sterile sheets and linens b. performing strict hand washing technique c. wearing gloves and gown only when giving direct care to the client d. wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

b. the first priority is halting the severity of the burn, to limit the depth of the burn and quick action must be a priority.

The nurse plans care for a male pt who suffered thermal burns to the entire posterior aspect of his body when he fell on an outdoor grill. Which pt need is likely to be the primary problem of this pt in the emergent phase? a. maintain tissue oxygenation b. halt progression of the burn c. maintain intravascular volume d. prevent invasion of pathogens

d, c, a, b.

The nurse plans emergent care for four male pt's who have burns covering between 40-50% of the total body surface area. Rank these patients according to their risk for an inhalation injury beginning with the pt who has the highest risk. a. has posterior chemical burns from an exhibit at a parking lot b. has osteoporosis and electrical burns of the lower extremities c. has thermal burns of the right side and is a volunteer fireman d. has chronic bronchitis and thermal burns around the abdomen

C. Circulation to the extremities can be severely impaired by deep circumferential burns and subsequent edema that impairs the blood supply. An escharotomy (electrocautery incision through the full-thickness eschar) is performed to restore circulation. Normal refill is less than 2 seconds.

The patient sustained a full-thickness burn encompassing the entire right arm. What is the best indicator an escharotomy achieved its desired effect? A. Patient rates the pain at less than 4. B. Blood pressure remains above 120/80 mm Hg. C. Right fingers blanch with a 2-second refill. D. Patient maintains full range of motion for the right arm.

b. eat a high-protein, low-fat, high-carbohydrate diet. The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

To maintain a positive nitrogen balance in a major burn, the patient must a. increase normal caloric intake by about 3 times b. eat a high-protein, low-fat, high-carbohydrate diet. c. eat at least 1500 calories per day in small, frequent meals. d. eat rice and whole wheat for the chemical effect on nitrogen balance

c. during the early postburn period, large amounts of plasma fluid extravasates into interstitial spaces. Restoring the fluid loss is necessary to prevent hypovolemic shock; this is best accomplished with crystalloid and colloid solutions.

What is the best method for preventing hypovolemic shock in a client admitted with severe burns? a. administering dopamine b. applying medical antishock trousers c. infusing i.v. fluids d. infusing fresh frozen plasma

a, d, e

When assessing a pt with a partial thickness burn, the nurse would expect to find (select all that apply) a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance

c. Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at a rate sufficient to maintain urinary output at 75 to 100 ml/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 ml/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.

When caring for a patient with an electrical burn injury, the nurse should question a health care provider's order for A. Mannitol 75 gm IV. B. Urine for myoglobulin. C. Lactated Ringer's at 25 ml/hr. D. Sodium bicarbonate 24 mEq every 4 hours.

d Rationale: Adequacy of fluid replacement is assessed by urine output and cardiac parameters. Urine output should be 0.5 to 1 mL/kg/hr. Mean arterial pressure should be >65 mm Hg, systolic BP >90 mm Hg, and heart rate <120 beats/min. A blood pressure of 86/72 indicates inadequate fluid replacement. However, the MAP is calculated at 77 mm Hg.

When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which finding is of most concern to the nurse? a) Serum K+ of 4.5 mEq/L b) Urine output of 35 mL/hr c) Decreased bowel sounds d) Blood pressure of 86/72 mm Hg

c. anterior head = 4.5%, upper half of anterior torso = 9%, lower half of both arms is 9%, posterior head 4.5%, upper half of posterior torso 9%, total 36%

The adult client was burned as a result of an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? a. 18% b. 24% c. 36% d. 48%

d.

The client arrives at the emergency department following a burn injury that occurred in the basement at home and an inhalation injury is suspected. Which of the following would the nurse anticipate to be prescribed for the client? a. 100% oxygen via an aerosol mask b. Oxygen via nasal cannula at 15L/min c. Oxygen via nasal cannula at 10L/min d. 100% oxygen via a tight fitting, non rebreather face mask

An 85-year-old patient is assessed to have a score of 16 on the Braden Scale. Based on this information, how should the nurse plan for this patient's care? a. Implement a q2hr turning schedule with skin assessment. b. Place DuoDerm on the patient's sacrum to prevent breakdown. c. Elevate the head of bed to 90 degrees when the patient is supine. d. Continue with weekly skin assessments with no special precautions.

Correct answer: a Rationale: *A patient with a total Braden score of 16 or less is considered to be at risk for pressure ulcers*. Pressure ulcers can be prevented by several strategies: using an established risk assessment tool; repositioning frequently (every 1 to 2 hours); using devices to reduce pressure and shearing force (e.g., alternating-pressure mattresses, foam mattresses, wheelchair cushions, padded commode seats, boots [foam, air], lift sheets); removing excessive moisture on the skin; avoiding massage over bony prominences; positioning with pillows; and assisting the patient in maintaining a healthy weight.

Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia? a. Urinary catheterization b. Administration of benzodiazepines c. Suctioning of the patient's upper airway d. Placement of the patient in the Trendelenburg position

Correct answer: a Rationale: Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. Benzodiazepines are contraindicated, and suctioning is likely unnecessary. The patient should be positioned upright.

The injury that is least likely to result in a full-thickness burn is a. sunburn. b. scald injury. c. chemical burn. d. electrical injury.

Correct answer: a Rationale: Full-thickness burns may be caused by contact with flames, scalding liquids, chemicals, tar, or electrical current.

For a 65-year-old woman who has lived with a T1 spinal cord injury for 20 years, which health teaching instructions should the nurse emphasize? a. A mammogram is needed every year. b. Bladder function tends to improve with age. c. Heart disease is not common in persons with spinal cord injury. d. As a person ages, the need to change body position is less important.

Correct answer: a Rationale: Health promotion and screening are important for an older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and undergo yearly mammography.

Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? a. Headache and rising blood pressure b. Irregular respirations and shortness of breath c. Decreased level of consciousness or hallucinations d. Abdominal distention and absence of bowel sounds

Correct answer: a Rationale: Manifestations of autonomic dysreflexia are -hypertension (up to 300 mm Hg systolic) -a throbbing headache -bradycardia -diaphoresis. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic manifestations.

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? a. Bradycardia b. Hypertension c. Neurogenic spasticity d. Bounding pedal pulses

Correct answer: a Rationale: Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a. applying pressure garments. b. repositioning the patient every 2 hours. c. performing active ROM at least every 4 hours. d. massaging the new tissue with water-based moisturizers.

Correct answer: a Rationale: Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.

To maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, low-fat, high-carbohydrate diet. b. increase normal caloric intake by about three times. c. eat at least 1500 calories/day in small, frequent meals. d. eat rice and whole wheat for the chemical effect on nitrogen balance.

Correct answer: a Rationale: The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delays in healing.

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? a. Central cord syndrome b. Spinal shock syndrome c. Anterior cord syndrome d. Brown-Séquard syndrome

Correct answer: b Rationale: About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. -Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. -Anterior cord syndrome results in motor and sensory loss but not reflexes. -Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient's WBC count is 15.0 × 106/µL, and he has coolness of the lower extremities, weighs 75 lb more than his ideal body weight, and smokes two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? a. Imbalanced nutrition: more than body requirements related to high-fat foods b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking c. Ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking d. Ineffective individual coping related to indifference and denial of the long-term effects of diabetes and smoking

Correct answer: b Rationale: Factors that can interfere with wound healing include malnutrition, obesity, decreased blood supply, tissue trauma, smoking, drugs (e.g., corticosteroids, chemotherapy), wound debris such as necrotic tissue, advancing age, diabetes mellitus, poor health, anemia, and infection

A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the wound bed. b. observe the wound for signs of infection during dressing changes. c. apply cool compresses for pain relief in between dressing changes. d. wash the wound aggressively with soap and water three times a day.

Correct answer: b Rationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis.

The nurse assessing a patient with a chronic leg wound finds local signs of erythema and pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? a. Serum protein analysis b. WBC count and differential c. Punch biopsy of center of wound d. Culture and sensitivity of the wound

Correct answer: b Rationale: Neutrophils and monocytes move from the circulation to the site of injury. *The bone marrow releases more neutrophils into circulation, which results in elevation of the WBC count, especially the neutrophil count. If the bone marrow releases immature forms of neutrophils (i.e., bands) into circulation, a shift to the left occurs*. Patients with acute bacterial infections have elevated WBC counts with a shift to the left.

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5° F temperature, slight erythema at the incision margins, and 30 mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. The abdominal incision shows signs of an infection. b. The patient is having a normal inflammatory response. c. The abdominal incision shows signs of impending dehiscence. d. The patient's physician needs to be notified about her condition.

Correct answer: b Rationale: The *local response* to inflammation includes the manifestations of redness, heat, pain, swelling, and loss of function. *Systemic* manifestations of inflammation include an increased white blood cell (WBC) count with a shift to the left, malaise, nausea and anorexia, increased pulse and respiratory rates, and fever.

Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temperature at 140° F (60° C). b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Never permit older adults to cook unattended.

Correct answer: c Rationale: A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Hot water heaters set at 140° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used. Supervision of older adults who are cooking is necessary only if cognitive alterations are observed.

The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? a. Pain assessment b. Glasgow Coma Scale c. Respiratory assessment d. Musculoskeletal assessment

Correct answer: c Rationale: Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status.

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the physician. b. check the patient's temperature. c. take the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

Correct answer: c Rationale: Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the injury, bradycardia (30 to 40 beats/min), piloerection, flushing of the skin above the level of the injury, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. *It is important to measure blood pressure when a patient with a spinal cord injury complains of headache*. Other nursing interventions in this serious emergency are elevation of the head of the bed 45 degrees or sitting the patient upright, notification of the physician, and assessment to determine the cause. Table 61-8 lists the causes and symptoms of autonomic dysreflexia. The nurse must monitor blood pressure frequently during the episode. An α-adrenergic blocker or an arteriolar vasodilator may be administered.

The nurse is caring for a patient with chronic constrictive pericarditis. Which assessment finding reflects a more serious complication of this condition? a. Fatigue b. Peripheral edema c. Jugular venous distention d. Thickened pericardium on echocardiography

Correct answer: c Rationale: Cardiac tamponade is a serious complication of pericarditis. As the compression of the heart increases, decreased left atrial filling results in decreases in cardiac output. Neck veins usually are markedly distended as a result of jugular venous pressure elevation related to compression of the right side of the heart.

An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage I b. Stage II c. Stage III d. Stage IV

Correct answer: c Rationale: Characteristics of a stage III ulcer include full-thickness tissue loss; visibility of subcutaneous fat but not of bone, tendon, and muscle; and slough that may be present but does not obscure the depth of tissue loss and that may include undermining and tunneling.

A patient is recovering from second- and third-degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. teach the patient and the caregiver proper wound care to be performed at home. c. review the patient's current health care status and readiness for discharge to home. d. give the patient written discharge information and websites for additional information for burn survivors.

Correct answer: c Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The health care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge.

A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority during rehabilitation? a. Prevent urinary tract infections. b. Monitor the patient every 15 minutes. c. Encourage him to verbalize his feelings. d. Teach him about using the gastrocolic reflex.

Correct answer: c Rationale: To help him with his coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages his self-expression and verbalization of thoughts and feelings. This patient is at high risk for depression and self-injury because he is likely to lose function below the umbilicus involving lost motor and sensory function. In addition, he is a young adult male patient who is likely to need a wheelchair, have impaired sexual function, and is unlikely to resume his racing career. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits that can make coping especially difficult for him. Prevention of urinary tract infections and facilitating bowel evacuation with the gastrocolic reflex will be important but not as important as helping him cope. In rehabilitation, monitoring every 15 minutes is not needed unless he is on a suicide watch.

Which one of the orders should a nurse question in the plan of care for a patient with a stage III pressure ulcer? a. Pack the ulcer with foam dressing. b. Turn and position the patient every 2 hours. c. Clean the ulcer every shift with Dakin's solution. d. Assess for pain and medicate before dressing change.

Correct answer: c Rationale: Topical antimicrobial and antibactericidal agents (e.g., povidone-iodine [Betadine], sodium hypochlorite [Dakin's solution], hydrogen peroxide [H2O2], chlorhexidine [Hibiclens]) should be used with caution in wound care because they can damage the new epithelium of healing tissue and delay healing. *These topical agents should never be used in a clean, granulating wound*.

A 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses is/are most appropriate (select all that apply)? a. Acute pain related to tissue damage and inflammation b. Impaired skin integrity related to immobility and decreased sensation c. Impaired tissue integrity related to inadequate circulation secondary to pressure d. Risk for infection related to loss of tissue integrity and undernutrition secondary to stroke

Correct answers: b, c Rationale: Priority nursing diagnoses for this patient are: -Impaired skin integrity -Impaired tissue integrity.

Goals of rehabilitation for the patient with an injury at the C6 level include (select all that apply) a. stand erect with leg brace. b. feed self with hand devices. c. assist with transfer activities. d. drive adapted van from wheelchair. e. push a wheelchair on a flat surface.

Correct answers: b, c, d, e Rationale: Rehabilitation goals for a patient with a spinal cord injury at the C6 level include the ability to assist with transfer and perform some self-care; feed self with hand devices; push a wheelchair on smooth, flat surfaces; drive an adapted van from a wheelchair; independent computer use with adaptive equipment; and need for attendant care for only 6 hours per day.

A 68-year-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl (Dulcolax) suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist the patient with bowel evacuation (select all that apply)? a. Drink more milk. Incorrect b. Eat 20-30 g of fiber per day. c. Use oral laxatives every day. d. Drink 1800 to 2800 mL of water or juice. e. Establish bowel evacuation time at bedtime

Correct answers: b, d Rationale: The patient with a spinal cord injury and neurogenic bowel should eat 20-30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Milk may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless necessary. Bowel evacuation time is usually established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

A patient with rheumatoid arthritis is experiencing articular involvement of the joints. The nurse recognizes that these characteristic changes include (select all that apply) a. bamboo-shaped fingers. b. metatarsal head dislocation in feet. c. noninflammatory pain in large joints. d. asymmetric involvement of small joints. e. morning stiffness lasting 60 minutes or more.

Correct answers: b, e Rationale: Morning stiffness may last from 60 minutes to several hours or more, depending on disease activity. Metatarsal head dislocation and subluxation in the feet may cause pain and walking disability. Joint symptoms occur symmetrically and frequently affect the small joints of the hands (proximal interphalangeal [PIP] and metacarpophalangeal [MCP] joints) and feet (metatarsophalangeal [MTP] joints). Larger peripheral joints such as the wrists, elbows, shoulders, knees, hips, ankles, and jaw may also be involved. Rheumatoid arthritis (RA) is an inflammatory disorder. In early disease, the fingers may become spindle-shaped from synovial hypertrophy and thickening of the joint capsule.

d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.

During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burn patients, hypovolemia occurs primarily as a result of a. Blood loss from injured tissue. b. Third spacing of fluid into fluid-filled vesicles. c. Evaporation of fluid from denuded body surfaces. d. Capillary permeability with fluid shift to the interstitium.

c. sequestering of sodium and water in the interstitial fluid.

Fluid and electrolyte shifts that occur during the early emergent phase include a. adherence of albumin to vascular walls b. movement of potassium into the vascular space c. sequestering of sodium and water in the interstitial fluid. d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

c.

Knowing the most common causes of household fires, which of the following prevention strategies would the nurse focus on when teaching about fire safety? a. set how water temp at 140 F b. use only hardwired smoke detectors c. encourage regular home fire exit drills d. never permit older adults to cook unattended.

D. Airway injury is a priority, and stridor results from a narrowing of the airway caused by edema. A history of prednisone use or diabetes is a concern for long-term infection risk, but the airway is always first.

Multiple patients arrive in the emergency department from a house fire. Which patient is a priority? A. Patient with erythremic, dry burns over the arms and a history of taking prednisone B. Patient with moist blisters over the chest and who reports pain as 10 C. Patient with dry, black skin on one hand and a history of diabetes mellitus D. Patient with multiple reddened skin areas on the chest and with high-pitched respiratory sounds

2. A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates that the next action will be to a. obtain wound cultures. b. start antibiotic therapy. c. redress the wound with wet-to-dry dressings. d. continue to monitor the wound for purulent drainage.

ANS: A The shift to the left indicates that the patient probably has a bacterial infection, and the nurse will plan to obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.

9. A patient is admitted to the hospital with a pressure ulcer on the left buttock. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage a. I. b. II. c. III. d. IV.

ANS: C A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.

6. A 76-year-old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. The nurse documents the wound as a a. red wound. b. yellow wound. c. full-thickness wound. d. stage III pressure wound.

ANS: B The description is consistent with a yellow wound. A stage III pressure wound would expose subcutaneous fat. A red wound would not have any creamy colored exudate. A full-thickness wound involves subcutaneous tissue, which is not indicated in the wound description.

1. The nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention; the nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

3. A patient with a systemic bacterial infection has "goose pimples," feels cold, and has a shaking chill. At this stage of the febrile response, the nurse will plan to monitor for a. skin flushing. b. muscle cramps. c. rising body temperature. d. decreasing blood pressure.

ANS: C The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with rising temperatures.

5. A patient's 6 3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing will the nurse use for wound care? a. Dry gauze dressing (Kerlix) b. Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)

ANS: C The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.

4. A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient's oral temperature again in 4 hours.

ANS: D Mild to moderate temperature elevations (less than 103° F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms. There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation.

12. The charge nurse observes a new graduate performing a dressing change on a stage II left heel pressure ulcer. Which action by the new graduate indicates a need for further education about pressure ulcer care? a. The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b. The new graduate inserts a sterile cotton-tipped applicator into the pressure ulcer. c. The new graduate irrigates the pressure ulcer with a 30-ml syringe using sterile saline. d. The new graduate cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

ANS: D Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new graduate are appropriate.

10. A patient who is confined to bed and who has a stage II pressure ulcer is being cared for in the home by family members. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to a. change the patient's bedding frequently. b. use a hydrocolloid dressing over the ulcer. c. record the size and appearance of the ulcer weekly. d. change the patient's position at least every 2 hours.

ANS: D The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions also may be included in family teaching, but the most important instruction is to change the patient's position at least every 2 hours.

8. The nurse will plan to use wet-to-dry dressings when providing care for a patient with a a. pressure ulcer with pink granulation tissue. b. surgical incision with pink, approximated edges. c. full-thickness burn filled with dry, black material. d. wound with purulent drainage and dry brown areas.

ANS: D Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.

17. When caring for a diabetic patient who had abdominal surgery one week ago, the nurse obtains these data. Which finding should be reported immediately to the health care provider? a. Blood glucose 136 mg/dl b. Oral temperature 101° F (38.3° C) c. Patient complaint of increased incisional pain d. New 5-cm separation of the proximal wound edges

ANS: D Wound separation at a week postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings also will be reported, but do not require intervention as rapidly.

14. When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient states that the ulcers are very painful. b. The patient has had the heel ulcers for the last 6 months. c. The patient has several old incisions that have formed keloids. d. The patient takes corticosteroids daily for rheumatoid arthritis.

ANS: D Chronic corticosteroid use will interfere with wound healing. The persistence of the ulcers over the last 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patient's pain will be implemented, but pain does not impact directly on wound healing.

7. Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.

ANS: D Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be "just not feeling well."

15. The nurse has just received change-of-shift report about the following four patients. Which patient will the nurse assess first? a. The patient who has multiple black wounds on the feet and ankles. b. The newly admitted patient with a stage IV pressure ulcer on the coccyx. c. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change. d. The patient who has been receiving immunosuppressant medications and has a temperature of 102° F.

ANS: D Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other patients as soon as possible after assessing and implementing appropriate care for the immunosuppressed patient.

16. Which of these four patients should the medical-surgical unit charge nurse assign to an LPN team member? a. The patient who has increased tenderness and swelling around a leg wound. b. The patient who has just arrived after suturing of a full-thickness arm wound. c. The patient who needs teaching about home care for a draining abdominal wound. d. The patient who requires a hydrocolloid dressing change for a Stage III sacral ulcer.

ANS: D LPN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the RN.

A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? a. Tertiary intention b. Secondary intention c. Regeneration of cells d. Remodeling of tissues

Correct answer: b Rationale: A pressure ulcer can provoke an inflammatory reaction that results in large amounts of exudate and wide, irregular wound margins with extensive tissue loss. Pressure ulcers may have edges that cannot be approximated. This type of wound heals by secondary intention. The healing and granulation take place from the edges inward and from the bottom of the wound upward until the defect is filled. Granulation tissue develops, and a large scar results.

A patient in the unit has a 103.7° F temperature. Which intervention would be most effective in restoring normal body temperature? a. Use a cooling blanket while the patient is febrile. b. Administer antipyretics on an around-the-clock schedule. c. Provide increased fluids and have the UAP give sponge baths. d. Give prescribed antibiotics and provide warm blankets for comfort.

Correct answer: b Rationale: Antipyretics are used to lower the body temperature and should be given around the clock to prevent acute swings in temperature. Chills may be evoked or perpetuated by the intermittent administration of antipyretics. These agents cause a sharp decrease in temperature. When an antipyretic wears off, the body may initiate a compensatory involuntary muscular contraction (i.e., chill) to raise the body temperature up to its previous level. This unpleasant side effect of antipyretic drugs can be prevented by administering the agents regularly and frequently at 2- to 4-hour intervals. Sponge baths and cooling blankets may not decrease the body temperature unless antipyretic drugs have been given to lower the set point. Otherwise, the body will initiate compensatory mechanisms (e.g., shivering) to restore body heat.

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls. b. movement of potassium into the vascular space. c. sequestering of sodium and water in interstitial fluid. d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

Correct answer: c Rationale: During the emergency phase, sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases. • Na+ rapidly moves into interstitial spaces and remains until edema formation ceases • K+ shift develops because injured cells and hemolyzed RBC's release K+ into extracellular spaces

b. the patient has as much control over the management of the pain as possible. The more control the patient has in managing the pain, the more successful the chosen strategies. Active patient participation has been found to be effective for some patients in anticipating and coping with treatment-induced pain.

Pain management for the burn patient is most effective when a. opoids are administered on a set schedule around the clock b. the patient has as much control over the management of the pain as possible. c. there is flexibility to administer opioids withing a dosage and frequency range d. painful dressing changes are delayed until the pt's pain is totally relieved.

c. burns and the resulting low circulating fluid volume can cause hypovolemic shock.

The condition of a client with extensive third degree burns begins to deteriorate. The nurse is aware that which type of shock may occur as a result of inadequate circulating blood volume that occurs with a burn injury? a. cardiogenic b. distributive c. hypovolemic d. septic

c. Until a complete assessment and treatment plan are initiated, the child should be kept NPO. A complication of major burns is paralytic ileus, so until that has been ruled out, oral fluids should not be provided.

A child has just been admitted to the pediatric burn unit. Currently, the child is being evaluated for burns to his chest and upper legs. He complains of thirst and asks for a drink. What is the most appropriate nursing action? a. give a small glass of clear liquid b. give a small glass of a full liquid c. keep the child NPO d. order a pediatric meal tray with extra liquids

a. coughing and wheezing may indicate that the child has inhaled smoke or toxic fumes. Maintaining airway patency is the highest nursing priority in this situation.

A child was admitted to the ED with a thermal burn to the right arm and leg. Which assessment by the nurse requires immediate action? a. coughing and wheezing b. bright red skin with small blister on the burn sites c. thirst d. singed hair

c. fluid management during the first 24 hours following a burn injury generally includes the infusion of LR solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30mL/hr. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, should expect ↑ of LR's.

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50, a pulse of 110, and urine output of 20 mL over the past hour. The nurse reports the findings to the physician and anticipates which of the following prescriptions? a. transfusing 1 unit of packed red blood cells b. administering a diuretic to increase urine output c. increasing the amount of IV lactated Ringers solution administered per hour d. changing the IV lactated Ringer's solution to one that contains dextrose in water.

c. this pt is most likely experiencing hyperglycemic hyperosmolar nonketotic syndrome (HHNKS) which dehydrates a patient rapidly. This increases the pt's risk for hypovolemia and hypotension.

A female pt in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose of 485 mg/dL. What is the nurse's priority for preventing a life threatening complication of hyperglycemia for the burn patient? a. replace the blood lost b. maintain a neutral pH c. Maintain fluid balance d. Replace serum potassium

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters. b. exposed fascia. c. exposed muscles. d. intact nerve endings. e. red, shiny, wet appearance.

Correct answers: a, d, e Rationale: The appearance of *partial-thickness (deep)* (dermis) burns may include fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema.

A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? a. "Blood loss from burned tissue is the most likely cause of hypovolemia." b. "Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia." c. "The usual cause of hypovolemia is vaporation of fluid from denuded body surfaces." d. "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

Correct answer: d Rationale: • Greatest threat is hypovolemic shock; Caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability o Can begin as early as 20 minutes post-burn • Colloidal osmotic pressure decreases • More fluid shifting out of the vascular space into interstitial space; Second spacing • As the capillary walls become more permeable, water, sodium, and later plasma proteins (especially albumin) move into interstitial spaces and other surrounding tissue. • The colloidal osmotic pressure decreases with progressive loss of protein from the vascular space. This results in more fluid shifting out of the vascular space into the interstitial spaces. (Fluid accumulation in the interstitium is termed second spacing.) • Fluid also moves to areas that normally have minimal to no fluid, a phenomenon termed third spacing. o Examples of third spacing in burn injury are exudate and blister formation, as well as edema in non-burned areas • Normal insensible loss: 30-50 mL/hour • Severely burned patient: 200-400 mL/hour • The net result of the fluid shifts and losses is termed intravascular volume depletion o Edema • ↓ Blood pressure • ↑ Pulse

A patient is admitted to the ICU with a C7 spinal cord injury and diagnosed with Brown-Séquard syndrome. On physical examination, the nurse would most likely find a. upper extremity weakness only. b. complete motor and sensory loss below C7. c. loss of position sense and vibration in both lower extremities. d. ipsilateral motor loss and contralateral sensory loss below C7.

Correct answer: d Rationale: Brown-Séquard syndrome is a result of damage to one half of the spinal cord. This syndrome is characterized by a loss of motor function, position sense, and vibratory sense, as well as by vasomotor paralysis on the same side (ipsilateral) as the injury. The opposite (contralateral) side has loss of pain and temperature sensation below the level of the injury.

During routine assessment of a patient with Guillain-Barré syndrome, the nurse finds the patient is short of breath. The patient's respiratory distress is caused by a. elevated protein levels in the CSF. b. immobility resulting from ascending paralysis. c. degeneration of motor neurons in the brainstem and spinal cord. d. paralysis ascending to the nerves that stimulate the thoracic area.

Correct answer: d Rationale: Guillain-Barré syndrome is characterized by ascending, symmetric paralysis that usually affects cranial nerves and the peripheral nervous system. The most serious complication of this syndrome is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area.

A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. Obtain vital signs and a STAT arterial blood gas. b. Encourage the patient to cough and auscultate the lungs again. c. Document the findings and continue to monitor the patient's breathing. d. Anticipate the need for endotracheal intubation and notify the physician.

Correct answer: d Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority? a. Risk for impairment of tissue integrity caused by paralysis b. Altered patterns of urinary elimination caused by tetraplegia c. Altered family and individual coping caused by the extent of trauma d. Ineffective airway clearance caused by high cervical spinal cord injury

Correct answer: d Rationale: Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's BP is 84/50 mm Hg, his pulse is 38 beats/minute, and he remains orally intubated. The nurse determines that this pathophysiologic response is caused by a. increased vasomotor tone after injury. b. a temporary loss of sensation and flaccid paralysis below the level of injury. c. loss of parasympathetic nervous system innervation resulting in vasoconstriction. d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation.

Correct answer: d Rationale: Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decrease in cardiac output. These effects are usually associated with a cervical or high thoracic injury (T6 or higher).

Pain management for the burn patient is most effective when (select all that apply) a. a pain rating tool is used to monitor the patient's level of pain. b. painful dressing changes are delayed until the patient's pain is completely relieved. c. the patient is informed about and has some control over the management of the pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury.

Correct answers: a, c, d Rationale: The use of a pain rating tool assists the nurse in the assessment, monitoring, and evaluation of the pain management plan. The more control the patient has in managing the pain, the more successful the chosen strategies are. A selected variety of medications offer better pain relief for patients with burns, whose pain can be both continuous and treatment related over varying periods of time. It is not realistic to promise a patient that pain will be completely eliminated. It is not realistic to suggest that pain will be managed (during any phase of burn care) with nonpharmacologic pain management. Such management is meant to be adjuvant and individualized