Burns

A patient with a flash burn injury is admitted to the emergency department. The nurse notes a bright red area with blisters that blanches with the application of pressure. The patient also reports severe pain when the burn is exposed to air. Which type of burn is present? Superficial burn Full-thickness burn Deep partial-thickness burn Superficial partial-thickness burn

Deep partial-thickness burn A bright red area with blisters, blanching upon pressure, and severe pain in the patient indicates a deep partial-thickness burn. Superficial and superficial partial-thickness burns are characterized by erythema, but no blisters, with pain and mild swelling. Full-thickness burns are characterized by dry, waxy, leathery skin that is insensitive to pain due to nerve destruction. p. 437

The nurse is reviewing the fluid and electrolyte shifts that occur during burn injury. Which of these occur during the emergent stage of a burn injury? Select all that apply. Movement of potassium into the cells. Adherence of albumin to vascular walls. Edema in nonburned areas (third-spacing). Elevated hematocrit caused by hemoconcentration. Movement of water and sodium to the interstitial fluid.

Edema in nonburned areas (third-spacing). Elevated hematocrit caused by hemoconcentration. Movement of water and sodium to the interstitial fluid.

A patient is brought to the emergency department (ED) following an inhalation injury. The patient has sustained burns on the face, neck, and chest due to a fire in the home. Which would help to confirm the diagnosis of upper airway injury? Select all that apply. Dyspnea Wheezing Hoarseness Singed nasal hair Difficulty in swallowing

Hoarseness Singed nasal hair Difficulty swallowing

A nurse is assessing a patient who was burned after contact with gasoline. For which complication does the nurse monitor? Liquefaction Systemic toxicity Protein hydrolysis Severe metabolic acidosis

Systemic toxicity

The nurse recalls which description as the most accurate regarding a deep partial-thickness burn? Painful with weeping blisters Minimal damage to the epidermis Charring visible in the deepest areas Necrotic tissue through all layers of the skin

Painful with weeping blisters

A nurse is teaching a group of parents how to reduce the risk for injury related to burns. Which statement by a participant indicates effective learning? "Frayed wires are OK to use at home." "I should hold regular home fire exit drills." "I should use gasoline with care to start a fire." "I should perform outdoor activities with caution during electrical storms."

"I should hold regular home fire exit drills." Regular home fire exit drills ensure the family knows the primary escape routes in case of any flame accidents at home. Frayed wires lack protective insulation, and contact may result in electrical injuries. Gasoline or kerosene should never be used to start a fire. Outdoor activities should be avoided during electrical storms. p. 430

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%

22.5% Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because 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 (4.5 + 9 + 9); the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area. Eighteen percent, 27%, and 36% are incorrect calculations. pp. 432-433

A nurse is caring for a patient who has sustained burns over the entire surfaces of both arms, the anterior trunk, and the right leg. The nurse uses the rule of nines to estimate the percentage of the burn surface area as what? 27% 36% 54% 72%

54% The " rule of nines" is a method used to determine the body surface area (BSA) of a burn injury. It assigns 9% to each arm, 9% to the head, 18% to the anterior torso, 18% to the posterior torso, 18% to each leg, and 1% to the genitals. The other answer options are incorrect applications of the rule of nines BSA estimate. pp. 432-433

A nurse is planning care for a patient with a 30% body surface area burn injury. Which statement regarding the nutritional status of this patient is true? Maintaining a hypermetabolic state reduces the patient's risk for infection. Decreased protein intake will decrease the chance of renal complications. Controlling the temperature of the environment reduces caloric requirements. A hypermetabolic state results in poor healing and increased protein and lipid needs.

A hypermetabolic state results in poor healing and increased protein and lipid needs. A burn injury causes a hypermetabolic state, resulting in protein and lipid catabolism that can inhibit wound healing. Therefore the patient with a burn injury requires increased calories and protein to enable the healing process. Protein intake in the burn patient should be increased to promote wound healing. Renal function is monitored for complications, which is low risk with burns, because the need for protein is increased. A hypermetabolic state is not desired and is a complication of a burn injury. Controlling the temperature of the environment has no effect on caloric requirements. p. 442

A patient arrives at the burn unit with large burns on the chest and abdomen. While assessing the patient, the nurse suspects full-thickness burns. What findings are likely to be found in the patient with full-thickness burns? Select all that apply. The patient is shivering. The burned areas have blisters. The burned areas are very painful. The patient has low blood pressure. The patient has absence of bowel sounds

The patient is shivering. The patient has low blood pressure. The patient has absence of bowel sounds The patient with severe burns is likely to be in shock from hypovolemia and may have low blood pressure. The patient experiences shivering as a result of chilling that is caused either by heat loss, anxiety, or pain. The patient with a larger burn area may develop a paralytic ileus, which may be accompanied with absent or decreased bowel sounds. The burned areas have blisters filled with fluid and protein in cases of partial-thickness burns. Superficial to moderate partial-thickness burns are very painful. p. 437

Which statement from a co-worker regarding the fluid and electrolyte shifts that occur during burn injuries requires correction? "Exudate is an example of second spacing." "Accumulation of fluid in the interstitium is second spacing." "Edema and blister formation are examples of third spacing." "Movement of fluid to the areas with no or minimal fluid is third spacing."

"Exudate is an example of second spacing." Exudate is an example of third spacing. Accumulation of fluid in the interstitium is second spacing. Edema and blister formation are examples of third spacing. Third spacing is the movement of fluid to the areas with no or minimal fluid. p. 434

A nurse is assessing a patient with a burn injury. Which clinical manifestation does the nurse anticipate due to thrombosis in the capillaries of the burned tissue? Elevated heart rate Elevated hematocrit Decreased blood pressure Decreased erythrocyte count

Decreased erythrocyte count Thrombosis in the capillaries of burned tissue results in a loss of circulating erythrocytes (RBCs). An elevated heart rate and decreased blood pressure are signs of hypovolemic shock, which is caused by a massive shift of fluids out of the blood vessels. Hematocrit is elevated in burn injuries due to the hemoconcentration that results from fluid loss. p. 434

A nurse is providing care to a patient who was admitted to the hospital with third-degree burns. Which clinical manifestations should the nurse anticipate? Select all that apply. Erythema Fluid-filled vesicles Hard, leathery skin Insensitivity to pain Mild to moderate edema

Hard, leathery skin Insensitivity to pain Third-degree burns cause full-thickness skin destruction. Clinical manifestations include hard, leathery skin and insensitivity to pain due to nerve destruction. Erythema is observed in first-degree burns. Second-degree burns are characterized by fluid-filled vesicles and mild to moderate edema. p. 434

A patient is admitted to the burns ward with deep partial-thickness burns on the hands. What characteristics is the nurse likely to find when performing examination of the wound? Select all that apply. Wounds are painless. Wounds are wet and shiny. Wounds are painful to touch. Wounds appear pink to cherry-red. Wounds appear black and leathery.

Wounds are wet and shiny. Wounds are painful to touch. Wounds appear pink to cherry-red. Partial-thickness wounds are wet and shiny due to serous exudates. These wounds are painful to touch due to nerve injury. Wounds appear pink to cherry-red. Wounds are painless in full-thickness burns due to nerve destruction. Wounds appear black and leathery in full-thickness burns, because all skin elements and local nerve endings are destroyed, and coagulation necrosis is present. p. 439

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens? Serum sodium and potassium increase Serum sodium and potassium decrease Edema and arterial blood gases improve Diuresis occurs and hematocrit decreases

Diuresis occurs and hematocrit decreases In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock, and edema are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize. pp. 434, 436

A patient who escaped from a burning building, which was enclosed with no ventilation, is brought to the emergency department. The patient is confused, has difficulty breathing, and has nasal burns. Which condition does the nurse suspect? Pulmonary edema Lower airway injury Upper airway injury Carbon monoxide poisoning

Lower airway injury A patient who was trapped in an enclosed burning building with no ventilation and is exhibiting confusion, dyspnea, and nasal burns is most likely experiencing a lower airway burn injury. Pulmonary edema may occur but not until 12 to 24 hours after the initial insult. Clinical manifestations of an upper airway injury include blisters, edema, difficulty in swallowing, and total airway obstruction. Carbon monoxide poisoning results in hypoxia, in which oxygen consumption is impaired. p. 431

A nurse working in a burn unit identifies that which patients are at an increased risk of developing venous thromboembolism? Select all that apply. Young age Morbid obesity Prolonged immobility Upper-extremity burns First-degree burn of a finger

Morbid obesity Prolonged immobility The risk factors for the development of venous thromboembolism a burn patient are morbid obesity and prolonged immobility. These patients may develop stasis of blood due to immobility, which results in development of venous thromboembolism. Young age is not a risk factor for venous thromboembolism; rather, old age predisposes a person to venous thromboembolism. Usually lower-extremity burns are risk factors for venous thromboembolism, because they cause stagnation of blood. First-degree burn of a finger is not an extensive burn and hence not a risk factor for venous thromboembolism. p. 437

An unconscious patient who suffered an electrical burn is admitted to the emergency department. For which complications will the nurse monitor? Select all that apply. Myoglobinuria Systemic toxicity Pulmonary edema Cervical spine injury Severe metabolic acidosis

Myoglobinuria Cervical spine injury Severe metabolic acidosis Patients with an electrical injury are at risk from myoglobinuria, cervical spine injury, and severe metabolic acidosis. Myoglobinuria occurs because myoglobin from the injured tissue is released into circulation, causing muscle and blood vessel damage. Contact with electrical currents causes muscle contractions, which can fracture the vertebrae and bones. Electrical injury carries the risk of severe metabolic acidosis. Systemic toxicity occurs in patients with chemical burns. Pulmonary edema occurs due to smoke and inhalation injuries. p. 431

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 manifestation? Blisters Reddening of the skin Destruction of all skin layers Damage to sebaceous glands

Reddening of the skin 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. p. 432

A patient presents in the emergency department with a bright red burned area, with moist, red, shiny vesicles and blister formation. The patient reports severe pain when the site is exposed to air. Which type of burn will the nurse document in the patient's medical record? First-degree burn Third-degree burn Fourth-degree burn Second-degree burn

Second-degree burn A second-degree burn manifests as a bright red burned area with moist, red, shiny vesicles and blister formation. There is also severe pain upon exposure to air. In first-degree burns, there is erythema, blanching on application of pressure, and no vesicles or blisters. Third- and fourth-degree burns are characterized by dry, waxy, leathery skin that is insensitive to pain. p. 432

A nurse is providing care to a patient with burn injuries. Laboratory tests indicate the patient is experiencing hypernatremia. For which clinical manifestations should the nurse monitor? Select all that apply. Seizures Paresthesia Tachycardia Muscle cramps Dried, furry tongue

Seizures Dried, furry tongue

A patient who sustained burns in a house fire develops a paralytic ileus. What does the nurse suspect to be the cause of this complication? Sepsis Enteral feedings Opioid analgesics Increased gastric acid secretion

Sepsis Paralytic ileus is caused when the burn patient experiences sepsis. Enteral feedings may cause the patient to experience diarrhea. Constipation is a side effect for opioid analgesics, which are required for pain management. Curling's ulcer occurs as a result of increased gastric acid secretion. p. 443

A patient is admitted to the burn unit with second-degree thermal burns. Which characteristics of a second-degree thermal burn should the nurse expect to find during the physical assessment? Select all that apply. Severe pain Mild edema Fluid-filled vesicles Waxy, white, hard skin Visible thrombosed vessels

Severe pain Mild edema Fluid-filled vesicles Second-degree burns show epidermal and dermal involvement to varying depths. These burn injuries are characterized by fluid-filled vesicles that are erythematous, glossy, and damp. The patient may complain of severe pain caused by nerve injury. Mild to moderate edema may be present. Waxy, white, hard skin and visible thrombosed vessels are found in third-degree burns. p. 432

A nurse is providing care to a patient who presents with a second degree burn. When assessing this patient, which clinical manifestations should the nurse anticipate? Select all that apply. Blanching Severe pain White, waxy skin Red, shiny vesicles Mild to moderate edema

Severe pain Red, shiny vesicles Mild to moderate edema Clinical manifestations of second-degree burns include severe pain, the appearance of fluid-filled vesicles, the appearance of "shiny" skin, and mild to moderate edema. Blanching is observed in first-degree burns, and white, waxy skin is seen in third- and fourth-degree burns. p. 434

A patient is brought to the emergency department (ED) with severe burns on the legs and feet. Which factors lead the nurse to believe the patient may have full-thickness burns? Select all that apply. Touch sensation is impaired. Blanching with pressure is observed. Lack of blanching with pressure is observed. Wounds appear mottled white, pink to cherry-red. Wounds appear waxy white, dark brown, or charred.

Touch sensation is impaired. Lack of blanching with pressure is observed. Wounds appear waxy white, dark brown, or charred Touch sensation is impaired due to impaired nerve endings in full-thickness burns. Lack of blanching with pressure is observed, because all skin elements are destroyed. Wounds appear waxy white, dark brown, or charred in full-thickness burns, because all skin elements and local nerve endings are destroyed, and coagulation necrosis is present. Blanching with pressure is observed in partial-thickness burns, because varying degrees of both the epidermis and dermis are involved, and skin elements of regeneration are viable. Wounds appear mottled white, pink to cherry-red in a partial-thickness burn. p. 434

While assessing a patient with severe burns, the nurse suspects hypokalemia. What possible causes should the nurse evaluate? Select all that apply. Vomiting Renal failure Adrenal insufficiency IV therapy without potassium Prolonged gastrointestinal (GI) suction

Vomiting IV therapy without potassium Prolonged gastrointestinal (GI) suction Hypokalemia occurs due to lack of potassium. Excessive vomiting causes loss of body fluids leading to a loss of potassium. Prolonged GI suction also causes fluid loss and decreases potassium levels. The IV therapy without potassium fails to compensate for the loss of potassium, and the deficiency persists thus resulting in hypokalemia. Renal failure and adrenal insufficiency are the causes of hyperkalemia, which is marked by an increase in potassium levels. p. 443