Chapter 57

A triage nurse in the emergency department (ED) receives a phone call from a frantic parent who saw their 4-year-old child tip a pot of boiling water onto themselves. The parent has called an ambulance. What should the nurse in the ED receiving the call instruct the parent to do? A. Cover the burn with ice and secure with a towel. B. Apply butter to the area that is burned. C. Immerse the child in a cool bath. D. Avoid touching the burned area under any circumstances.

C. Immerse the child in a cool bath.

Burns more than 40% of TBSA produce a local and systemic response and are considered major burns.

FALSE

Mortality associated with burns is greater in younger patients than in older adult patients when comparing injuries with similar severity.

FALSE

The initial systemic event, after a major burn injury, is a shift of fluid, sodium, and protein resulting in ______________ shock.

Hypovolemic

A major part of the nurse's role during the acute phase of burn care is detection and prevention of ____________.

Infection

A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication? A. Psychosis B. Posttraumatic stress disorder C. Delirium D. Vascular dementia

B. Posttraumatic stress disorder

The body's response to burn injuries has been classified as hyperdynamic, _________, and hypercatabolic.

Hypermetabolic

A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does the client most likely have, measured as a percentage?

18%

A client is admitted to the burn unit after being transported a long distance. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A. Ischemia B. Referred pain C. Cellulitis D. Venous thromboembolism (VTE)

A. Ischemia

A public health nurse is educating a group of administrators about decreasing hospitalizations for burns. Which population will the nurse note as the target population for burn injuries? A. Older adults B. Women more than men C. Adults 35-40 years of age D. School-aged teenagers

A. Older adults

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A. Sodium deficit B. Decreased prothrombin time (PT) C. Potassium deficit D. Decreased hematocrit

A. Sodium deficit

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood? A. The client is likely experiencing a delayed onset of respiratory complications B. The client has likely developed a systemic infection C. The client's respiratory complications are likely related to psychosocial stress D. The client is likely experiencing an anaphylactic reaction to a medication

A. The client is likely experiencing a delayed onset of respiratory complications

A nurse who is taking care of a client with burns is asked by a family member why the client is losing so much weight. The client is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A. "The client is on a calorie-restricted diet in order to divert energy to wound healing." B. "The client's body has consumed fat deposits for fuel because calorie intake is lower than normal." C. "The client actually hasn't lost weight. Instead, there's been a change in the distribution of body fat." D. "The client lost many fluids while being treated in the emergency phase of burn care."

B. "The client's body has consumed fat deposits for fuel because calorie intake is lower than normal."

An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A. The causative agent B. The client's pre-injury health status C. The client's prognosis for recovery D. The circumstances of the accident

B. The client's pre-injury health status

A nurse who provides care on a burn unit is preparing to apply a client's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A. Apply the new ointment without disturbing the existing layer of ointment. B. Apply the ointment using a sterile tongue depressor. C. Apply a layer of ointment approximately 1/16 inch thick. D. Gently irrigate the wound bed after applying the antibiotic ointment.

C. Apply a layer of ointment approximately 1/16 inch thick.

A client has experienced burns to the upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A. Instruct the client to keep the wound site in a dependent position. B. Administer PRN analgesia as prescribed. C. Assess the client's peripheral pulses distal to the dressing. D. Assist with passive range-of-motion exercises to "set" the new dressing

C. Assess the client's peripheral pulses distal to the dressing.

A nurse is teaching a client with a partial-thickness wound how to wear the elastic pressure garment. How often should the nurse instruct the client to wear this garment? months B. During waking hours for 2 to 3 months after the injury C. Continuously D. At night while sleeping for a year after the injury

C. Continuously

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? A. Confusion B. High fever C. Decreased blood pressure D. Sudden agitation

C. Decreased blood pressure

A client experienced a 33% TBSA burn 72 hours ago. The nurse observes that the client's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A. Obtain an order to reduce the rate of the client's IV fluid infusion. B. Report the client's early signs of acute kidney injury (AKI). C. Recognize that the client is experiencing an expected onset of diuresis. D. Administer sodium chloride as prescribed to compensate for this fluid loss.

C. Recognize that the client is experiencing an expected onset of diuresis.

A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A. To prevent neuropathies B. To prevent wound breakdown C. To prevent contractures D. To prevent heterotopic ossification

C. To prevent contractures

A client with a partial-thickness burn injury had a xenograft applied 2 weeks ago. The nurse notices that the xenograft is separating from the burn wound. What is the nurse's most appropriate intervention? A. Reinforce the xenograft dressing with another piece of Biobrane. B. Remove the xenograft dressing and apply a new dressing. C. Trim away the separated xenograft. D. Notify the health care provider for further emergency-related orders.

C. Trim away the separated xenograft.

A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A. Activity intolerance B. Anxiety C. Ineffective coping D. Acute pain

D. Acute pain

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A. Pain B. Fluid balance C. Anxiety and fear D. Airway management

D. Airway management

A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A. Assess the client for signs of electrolyte imbalances. B. Administer fluids as prescribed. C. Assess the risk for injury recurrence. D. Assess the client's psychosocial state.

D. Assess the client's psychosocial state.

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A. 0.45% NaCl with 20 mEq/L KCl B. 0.45% NaCl with 40 mEq/L KCl C. Normal saline D. Lactated Ringer

D. Lactated Ringer

A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A. Maintenance of bed rest to aid healing B. Choosing appropriate splints and functional devices C. Administration of beta adrenergic blockers D. Prevention of venous thromboembolism

D. Prevention of venous thromboembolism

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized the nurse's technique. How should the nurse best interpret this client's behavior? A. The client may be experiencing an adverse drug reaction that is affecting cognition and behavior. B. The client may be experiencing neurologic or psychiatric complications of the client's injuries. C. The client may be experiencing inconsistencies in the care being provided. D. The client may be experiencing anger about current circumstances that the client is deflecting toward the nurse.

D. The client may be experiencing anger about current circumstances that the client is deflecting toward the nurse.

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? A. The length of time since the burn B. The location of burned skin surfaces C. The source of the burn D. The total body surface area (TBSA) affected by the burn

D. The total body surface area (TBSA) affected by the burn

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? A. Apply ice to the site of the burn for 5 to 10 minutes. B. Wrap the client's affected extremity in ice until help arrives. C. Apply an oil-based substance to the burned area until help arrives. D. Wrap cool towels around the affected extremity intermittently.

D. Wrap cool towels around the affected extremity intermittently.

Methods used to determine total body surface area burned include __________, Lund and Browder method, and Palmer method.

Rule of Nines

Burn pain has been described as one of the most severe forms of acute pain and includes background or resting pain, procedural pain, and breakthrough pain.

TRUE

During burn care fluid resuscitation the patients' response to fluid therapy is assessed every hour.

TRUE

Prevention of shock and respiratory distress are two immediate priorities of care during the emergent/resuscitative phase of burn injury.

TRUE

A burn that results in total destruction of the epidermis, dermis, and underlying tissue and lacks sensation is considered a ___________-degree burn.

Third

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which client is most likely to have life-threatening complications? A. A 4-year-old scald victim burned over 24% of the body B. A 27-year-old male burned over 36% of his body in a car accident C. A 39-year-old female client burned over 18% of her body D. A 60-year-old male burned over 16% of his body in a brush fire

A. A 4-year-old scald victim burned over 24% of the body

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs? A. A client-controlled analgesia (PCA) system B. Oral opioids supplemented by NSAIDs C. Distraction and relaxation techniques supplemented by NSAIDs D. A combination of benzodiazepines and topical anesthetics

A. A client-controlled analgesia (PCA) system

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A. Administer IV fluids. B. Administer broad-spectrum antibiotics. C. Administer IV potassium chloride. D. Administer packed red blood cells.

A. Administer IV fluids.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? A. Fluid status B. Risk of infection C. Nutritional status D. Psychosocial coping

A. Fluid status

A client is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply. A. Promote truthful communication. B. Avoid asking the client to make decisions. C. Teach the client coping strategies. D. Administer benzodiazepines as prescribed. E. Provide positive reinforcement.

A. Promote truthful communication. C. Teach the client coping strategies. E. Provide positive reinforcement.

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A. Perform mechanical débridement to remove the exudate and prevent further infection. B. Inform the primary care provider promptly because the graft may need to be removed. C. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. D. Document this finding as an expected phase of graft healing.

B. Inform the primary care provider promptly because the graft may need to be removed.

A client has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the health care provider to order for the wound? A. Silver sulfadiazine 1% (Silvadene) water-soluble cream B. Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C. Silver nitrate 0.5% aqueous solution D. Acticoat

B. Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? A. Emergent B. Immediate resuscitative C. Acute D. Rehabilitation

C. Acute

A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response? A. "That's something that you and your doctor will likely talk about after your scars mature." B. "That is something for you to talk to your doctor about because it's not a nursing responsibility." C. "I know this is really important to you, but you have to realize that no one can make you look like you used to." D. "Unfortunately, it's likely that these scars will look like this for the rest of your life."

A. "That's something that you and your doctor will likely talk about after your scars mature."

A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what event? A. Hemodynamic instability B. Gastrointestinal hypermotility C. Respiratory arrest D. Hypokalemia

A. Hemodynamic instability

A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what findings? A. Hyperkalemia, hyponatremia, elevated hematocrit B. Hypokalemia, hypernatremia, decreased hematocrit C. Hyperkalemia, hypernatremia, decreased hematocrit D. Hypokalemia, hyponatremia, elevated hematocrit

A. Hyperkalemia, hyponatremia, elevated hematocrit

A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A. Monitoring fluid and electrolyte imbalances B. Providing education to the client and family C. Treating infection D. Promoting thermoregulation

B. Providing education to the client and family

The nurse is providing education to a client that is scheduled for mechanical débridement of a wound. The nurse knows that mechanical débridement involves which element? A. A spontaneous separation of dead tissue from the viable tissue B. Removal of eschar until the point of pain and bleeding occurs C. Shaving of burned skin layers until bleeding, viable tissue is revealed D. Early closure of the wound

B. Removal of eschar until the point of pain and bleeding occurs

The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk? A. Apply skin emollients as prescribed after granulation has occurred. B. Keep injured areas immobilized whenever possible to promote healing. C. Administer oral or IV corticosteroids as prescribed. D. Encourage physical activity and range-of-motion exercises.

D. Encourage physical activity and range-of-motion exercises.

A client is brought to the emergency department from the site of a chemical fire, where the client suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm? A. Superficial partial thickness B. Deep partial thickness C. Full partial thickness D. Full thickness

D. Full thickness