NURS 241- Violence, Human trafficking, & Burns

What are some symptoms of DV or Human trafficking the nurse should look out for?

*Mental symptoms*: - PTSD - anxiety - depression - fear - not interacting - hopelessness - withdrawal * somatic symptoms*: - irritable bowel - pain - aches - skin changes - generalized discomfort * physical symptoms*: - Bruising - injury - burns - scars - broken bones - perineal injury *nursing assessment*: -fear of partner - occurs in all relationships and all ages -physical signs such as broken bones, healing injuries, or scars - Emotional signs such as shaming, intimidation, or controlling -Economical signs such as controlling money, withholding basic transportation and necessities, tracking phone or car use - Inappropriate clothing to hide physical signs such as scarves, long sleeves in summer, coats - Signs of controlling behavior such as partner and making healthcare decisions or controlling access to patient

Match the following characteristics to the classification of the following burns: a) superficial/1st degree, b) partial thickness/2nd degree, c) full thickness/3rd-4th degree 1) skin is reddened 2) blisters 3) charring 4) 3 to 6 day healing time 5) about 2 weeks healing time 6) 2 to 6 weeks healing time 7) weeks to months healing time 8) caused by scalds, flames, brief contact with hot objects 9) caused by scalds, flames, prolonged contact her objects, tar, Greece, chemicals, electricity 10) caused by sunburn, flash burns

*Superficial/1st degree burns*: 1) skin is reddened 4) 3 to 6 day healing time 10) caused by sunburn, flash burns * partial thickness/2nd degree burns*: 2) blisters 5) about 2 weeks healing time 8) caused by scalds, flames, brief contact with hot objects * Full thickness/3rd-4th degree burn*: 3) charring 6) 2 to 6 weeks healing time 7) weeks to months healing time 9) caused by scalds, flames, prolonged contact her objects, tar, Greece, chemicals, electricity

What are examples of vulnerable populations?

- Elder abuse - Domestic violence/intimate violence ( males or females) - Human trafficking - Child abuse - Incarcerated clients - Homeless population - transgendered clients - Religious persecution

What are potential effects of intimate partner violence on work and life?

- Loss of relationships - loss of job - children/elders may have a loss of contact with family or friends - Lack of acute health care - Lack of ongoing healthcare; denied routine care/check ups/prenatal care - finances and transportation controlled to restrict movement and freedom

What are examples of what to say for the nursing assessment for a patient with suspected domestic violence or human trafficking?

- are you having any problems with your partner? - have you been kicked, punched, slapped in the last six months? - are you afraid? Do you feel safe at home/work? - how is your stress level? -I started asking all my patients about relationship violence. I can help if that is going on with you. -How are things at home? -Do you feel you are in danger? -What experiences with violence have you had in your life? -Have you been touched in a way that makes you uncomfortable? -has anyone forced you to have sex? -What happens when you and your partner disagree? -Do you have a safe place to go in an emergency?

Pt was admitted at 0800 with 90% tbsa. Pt weighs 130 pounds. It is now 0900. Ands were the following questions: 1) Calculate their IV fluid replacement rate for 24 hrs 2) What IV solution would you use? 3) what will the IV rate be running at 1200? 4) what will the IV rate be running at 1900? 5) What is the best way to administer these fluids into the pts body

1) 59kg x 4ml (adult is 4; child is 3) x 90% tbsa = *21,240 mls/24hrs* 2) Lactated ringers or Ringers lactate 3) 1st half of 21,240 mls is 10,620 ml/8hrs= *1,328 ml/hr* 4) 2nd half of 21,240 mls is 10,620 ml/16hrs= *664 ml/hr*

A patient experienced a 50% deep partial thickness burn injury five days ago. The nurse anticipates performing which of the following interventions to prevent complications at this stage of the burn injury? 1) Apply topical antimicrobial ointments to the burned areas. 2) Administer antibiotics via intraosseus infusion. 3) Administer 1000 mls of normal saline per hour. 4) Restrict calories to prevent acidosis.

1) Apply topical antimicrobial ointments to the burned areas. *Yes. This is likely the acute phase, when wound care will be occurring. Applying topical antibiotics are a good way to prevent localized infection and also to 'cover' the burned area.

The nurse is documenting a suspected domestic violence injury. Which of the following demonstrates the best example of narrative charting for this assessment finding? 1) Approximate 6 cm pattern contusion approximately 3 cm to right of umbillicus 2) The perpetrator stomped on the victim with a boot and left a mark. 3) Contusion with pattern, just right of midline abdomen. 4) Wiggly lines on the right side of the stomach

1) Approximate 6 cm pattern contusion approximately 3 cm to right of umbillicus *This is directly from the website posted in our course, 'Assessing Domestic Violence Injury". Check it out! Hint hint! Correct. This answer has the most objective data and includes measurements. This is a good example of "chart what you see".

The nurse is caring for a burn victim who presents with singed eyebrows and visible soot in the nostrils and hard palate. The paramedics report that the patient fell asleep while smoking. Which assessment finding(s) below would most alert the nurse to the patient's worsening condition? 1) Crackles, cough and restlessness 2) Increased CVP, peripheral edema; increased girth measurement 3) Low grade fever, hypoglycemia and hypoactive bowel sounds 4) Increased temperature, diuresis, decreased HCT

1) Crackles, cough and restlessness *Yes. These symptoms most connect with airway or inhalation injury.

The nurse is caring for a pt admitted 6 hours ago with deep partial thickness burns over the anterior chest, face and arms. Which of the following is an indication of the most concerning complication of burns at this stage? 1) Decreased blood pressure and diminished urine output 2) Intense shivering and resultant pain 3) Contractures and reduced range of motion 4) Increased blood sugar and caloric needs

1) Decreased blood pressure and diminished urine output *Yes. This demonstrates the initial fluid shift in the first several hours. As fluid leaves the vasculature, the pt is essentially hypovolemic as seen in the decreased BP. The pt's decreased urine output is also expected during this critical time, and should resolve with diuresis and increased urine output as the fluids shift back from the interstitial spaces to the vessels.

The nurse knows that which of the following are entry points for interpersonal violence victims for help and intervention? Select all that apply 1) OB appointment 2) Outpatient surgery for mole removal 3) Mental health support group 4) Emergency department following accident on highway 5) With friend or neighbor who is a mandatory reporter

1) OB appointment 2) Outpatient surgery for mole removal 3) Mental health support group 4) Emergency department following accident on highway 5) With friend or neighbor who is a mandatory reporter *All of these are points of entry for interpersonal violence victims. Nurses are mandatory reporters of all suspected abuse. Every person, every time.

The nurse is caring for a patient who sustained deep partial thickness burns over 67% of his body 4 days ago and is now in critical condition with the complication of DIC. Clinical manifestations of DIC include: 1) Petechiae; oozing of blood from multiple sites; hypovolemia 2) Loss of massive amounts of interstitial fluid due to loss of skin surface 3) Third space phenomenon; fluid collects in abdominal cavity causing hypovolemia 4) Small, focal areas of redness and edema in the most distal parts of the body

1) Petechiae; oozing of blood from multiple sites; hypovolemia *Yes. This describes DIC.

You are caring for a Veteran who was involved in combat where he experienced an explosion near a burn pit that left him with multiple burns. The patient tells you he has trouble sleeping and is having frequent flashbacks. He can't look at his burns during dressing changes, is asking his family to feed him, and is not participating in occupational and physical therapy. 1. What interventions would be appropriate for this patient? 2. What other member of the interprofessional team may you need to contact? 3. What teaching can you provide to the patient's family? 4. What specific Veteran-focused resources may be helpful to your patient?

1. Allow the patient to express his feelings; listen therapeutically and with empathy; review the patient's plan of care to see what earlier interventions may have been successful in encouraging patient participation; contact the health care provider to consider medications that address possible post-traumatic stress disorder; explore with patient if he may wish to speak with a member of the clergy or other spiritual supporter; contract with the patient to participate incrementally in care (e.g., "patient will look at burn for 2 seconds while nurse changes dressing" and incrementally tier participation over time so that patient can fully look at wound). 2. Health care provider, psychologist, physical and occupational therapists (to discuss how to collaboratively encourage participation in the plan of care); clergy or other spiritual supporter of the patient's choice. 3. Teach (and role-model) empathy for the patient's feelings; explain signs and symptoms associated with post-traumatic stress disorder; teach that coping with burns can take long periods of time; teach family how to be appropriately involved in patient's care so that they can assist, yet encourage patient toward participation in the plan of care. 4. The U.S. Department of Veterans Affairs has Environmental Health Coordinators that can assist with management of health issues sustained during military service.

You are caring for a patient who sustained burns that are pink, moist, sensate, and blanching. Vital signs show a heart rate of 150 beats per minute, and blood pressure of 90/30. The patient's urine output is 15 mL/hr. 1. Based on the information provided, is the patient experiencing signs of shock? 2. What degree burn does this patient have? Provide rationale. 3. How do you anticipate administering pain medication during the acute phase of burn injury? 4. With whom will you collaborate to provide the highest quality interprofessional care for this patient?

1. Yes. Diaphoresis, tachycardia, hypotension, change in mental status, decreased capillary refill, and urine output less than 0.5 mL/kg per hour are all signs of shock. 2. Partial thickness. There is still a good blood supply to the wound resulting in the color pink and blanching. The nerve endings are exposed resulting in pain and indicating that the dermis is intact. 3. You will anticipate giving pain medication intravenously because of problems with absorption from the muscle and the stomach. 4. Collaborate immediately with the healthcare provider, other nurses, pharmacist, and respiratory therapist; later, collaborate also with the case manager, social worker, psychologist, and spiritual leader of the patient's choice

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

1500 mL/hr *The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours.

The nurse knows that which of the following are included in the best definition of interpersonal violence? Select all that apply. 1) Affects mostly black and lower socioeconomic class people 2) Can include physical and/or sexual abuse 3) Can include homicide 4) Can include verbal abuse 5) Can include threats and manipulation

2) Can include physical and/or sexual abuse 3) Can include homicide 4) Can include verbal abuse 5) Can include threats and manipulation *Physical or sexual abuse is correct.; Homicide is a potential with interpersonal violence. Verbal abuse is correct. Threats and manipulation is correct.

The nurse knows that which of the following plans of care for the rehabilitative phase is the most appropriate? 1) Positioning to prevent extension, psychiatric support, diet consult for nutrition, dressing changes twice daily 2) Positioning to prevent flexion, psychiatric support, diet consult for nutrition, dressing changes twice daily 3) Positioning to prevent extension, psychiatric support, diet consult for nutrition, dressing changes 6 times daily 4) Positioning to prevent flexion, psychiatric support, diet consult for nutrition, dressing changes 6 times daily

2) Positioning to prevent flexion, psychiatric support, diet consult for nutrition, dressing changes twice daily *Yes. We do want to prevent flexion. This prevents contractures that may need surgical revision. The diet and psychiatric consultation is fine, and the amount of dressing changes seems about right, depending on the patient.

The nurse that which of the following is the most correct therapeutic question for the suspected victim of interpersonal violence? 1) "How about the weather? Great, huh?" 2) "Everything's ok with your sex life, right?" 3) " I routinely ask all of my patients about safety. Have you been hit, slapped, kicked or punched in the last 6 months?" 4) "You haven't been hurt at all, have you? 5) "Why do you make your partner so angry?"

3) " I routinely ask all of my patients about safety. Have you been hit, slapped, kicked or punched in the last 6 months?" *Correct. Asking specifically and directly about abuse is correct. You may also consider widening the timeframe to "in the last year' or "ever'.

The "Rule of Nines" helps assess the extent of a burn as well as to calculate fluid replacement needs and severity risk. If your patient sustained burns to: all of the posterior trunk, the whole back of the right leg and both sides/all of the right arm, what percentage of the body is burned? 1) 45% 2) 31.5% 3) 36% 4) 40.5%

3) 36% *This is a fairly straightforward addition of the areas burned and their percentages. You should have included full percentages for each area, as it stated "all of" each area was involved. If only half of the anterior leg was involved, say the knee to the toes on one side/anterior you would only count 4.5% instead of 9%.

The nurse is caring for a patient who is in shock following an extensive burn injury. What is the intravenous fluid of choice for this patient in the emergent phase of treatment? 1) 5% Dextrose in saline 2) 0.9 % normal saline 3) Lactated Ringers 4) Plasma

3) Lactated Ringers *Yes. This is the fluid of choice. You get a gold star!

An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) ____ drops/min

333 drops/min *1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min.

The nurse knows that which of the following statements is least effective to identify victims of human trafficking? 1) Do you have any ID? 2) Are you being forced to do something against your will? 3) Do you have to ask permission to do things? 4) Are your immunizations up to date? 5) Where do you live? Are you free to come and go?

4) Are your immunizations up to date? *This is not an effective statement. We care, but not right now.

The nurse is planning to discharge a patient following surgery for a fractured tibia, suspected to be a result of interpersonal violence at home. Which of the following statements is the most appropriate discharge plan? 1) The nurse will discharge the patient home with a list of resources, follow up appointments, discuss a safety plan, provide follow up legal services, and ensure there are follow up appointments. 2) The nurse will call a shelter, arrange transportation, give a list of phone numbers and resources, discuss a safety plan, provide follow up legal services, and ensure there are follow up appointments. 3) The nurse will call a shelter, arrange transportation, give a list of phone numbers and resources, and ensure there are follow up appointments. 4) The nurse will work with the social worker, discharge planning team, and security or police to call a shelter, arrange transportation, give a list of phone numbers and resources, discuss a safety plan, provide follow up legal services, and ensure there are follow up appointments.

4) The nurse will work with the social worker, discharge planning team, and security or police to call a shelter, arrange transportation, give a list of phone numbers and resources, discuss a safety plan, provide follow up legal services, and ensure there are follow up appointments. *Correct. This is the correct answer. You can't do this alone, nor do you have time. Using your interdisciplinary team is something you will need to do, and NCLEX will want you to do so as well! Management of care!!

The nurse suspects they are treating a victim of human sex trafficking. What labs, test, or interventions should the nurse most consider recommending to the provider? 1) STD screen, drugs of abuse screen, BUN/creat 2) STD screen, height/weight for age, thyroid levels 3) Urinalysis, STD screen, iron levels 4) Urinalysis, drugs of abuse screen, pregnancy test

4) Urinalysis, drugs of abuse screen, pregnancy test *The overall perfect set of labs/tests? Possibly U/A, STD screen, drugs of abuse screen, height/weight/age for nutritional status, pregnancy test, possible CT/MRI for any injury, mental health screening tests for depression, anxiety, PTSD. Skin inspection for infection, rash, any 'special' tattoos or branding, perineal inspection, etc. Correct. Out of the choices you were given, this one best assesses for common findings in human sex trafficking victims. A pregnancy test is a automatic test in sexual abuse and/or rape.

Which of the following is not an actual human trafficking assistance service? No feedback or rationales here - you are going to have to do the work to find out what is nationally available to you, the nurse, and those you help. Please take a few minutes and look at each of these websites! 1) polarisproject.org 2) nhtrc.org 3) www.ojjdp.gov 4) catwinternational.org 5) www.nps.gov

5) www.nps.gov

Calculate the hourly fluid rate for an adult who weights 200 lb & has burns on 50% of their TBSA. The burn occurred at 3 pm & it is now 3am.

568 ml/hr

Calculate fluid resuscitation of a 22lb child with a 45% tbsa burn for a rate @ 6 hrs post burn _____ ml/hr then rate at 18 hrs post burn _____ ml/hr

84.4 ml/hr; 422.2 ml/hr

Patient was covered in gas and set on fire and arrived in the ED at 0800. Calculate the percentage of the patient's body that is burned using the rule of nines chart below. What percentage of her body is burned? Half of head (9%) All of Front Chest (18%) All of Back chest (18%) All of arms (9% each) All of right leg (18%) All of back and half of front left leg (18%)

90%

What are potential barriers for the nurse during the assessment for a patient with suspected domestic violence or human trafficking? Select all that apply A. Afraid of being wrong B. Not sure what to look for C. Fear of saying the wrong thing D. Fear of making the situation worse E. Afraid of making an impact or difference in the situation F. Lack of time and interactions G. Fear of offending someone

A. Afraid of being wrong B. Not sure what to look for C. Fear of saying the wrong thing D. Fear of making the situation worse F. Lack of time and interactions G. Fear of offending someone *A sense of not being able to have an impact or difference in the situation

Which of the following are examples of vulnerable populations? Select all that apply A. Incarcerated clients B. Homeless population C. College students D. Religious persecution E. Elder abuse F. Human trafficking G. Child-abuse H. Transgendered clients I. Religious persecution J. Domestic violence

A. Incarcerated clients B. Homeless population D. Religious persecution E. Elder abuse F. Human trafficking G. Child-abuse H. Transgendered clients I. Religious persecution J. Domestic violence

Which of the following are red flags for domestic violence or human trafficking? Select all that apply A. Irritable bowel B. PTSD C. SIADH D. Interacting E. Broken bones F. Pain G. Fever H. Skin changes I. General discomfort

A. Irritable bowel B. PTSD E. Broken bones F. Pain H. Skin changes I. General discomfort * others include anxiety, depression, fear, not interacting, hopelessness, withdrawal, aches, bruising, injury, burns, scars, perineal injury

The nurse knows that which of the following are potential victims of human trafficking? Select all that apply. 1) Victims of sexual abuse 2) Adolescents with depression or other mental health issues 3) Women escaping domestic/interpersonal violence 4) Gay teens who feel disinfranchised from family, work, school, or friends 5) Children 'sold' to earn extra money for a family 6) People trying to pay off a debt such as with drugs 7) People who think they may be in love with the trafficker 8) A person from a foreign country who had help in getting a passport and visa to leave their country 9) Teens with unstable or chaotic home life

All of the above *Yes. Victims of sexual abuse may be targeted as part of the abuse cycle, or while they try to escape a situation. Yes. This is not limited to adolescents. Depression and mental health issues - especially untreated - may make people leave a situation hoping for something more elsewhere. People of any age with mental health issues also are a vulnerable population that may be taken advantage of/preyed upon. Yes. This is not limited to women. In this instance, the victim may need money, a place to stay, shelter for her children, or be preyed upon as a vulnerable population. Yes. Human trafficking is in a higher proportion in gay, lesbian, bisexual, queer or transgendered individuals. Nearly 40% of homeless youth identify as LGBTQ, in comparison to 7% of the general population. Youth without safe shelter and social supports are at higher risk of trafficking and exploitation. LGBTQ youth may be trafficked by intimate partners, family members, friends, or strangers. Yes. Although not as common in the U.S., children often times are 'sold' and/or coerced into forced labor, often with the false assumption by the family that the family will benefit. The children are frequently quickly removed from the home country to 'work' elsewhere. Yes. Often this is a vicious cycle of dependency on drugs, the promise of money or debt relief, and debt that never seems to get paid off. Often, substance abuse may continue as a maladaptive coping mechanism in some pretty awful and desperate HT situations. :( Yes. There are many stories of teens being approached online, and often the trafficker may make promises of romance, love, money, clothes, travel, vacation, jobs, material items, or other things as a way to gain access to the trafficked youth. Online trafficking is rampant among teenage girls. This fantasy of relationships or love with subsequent human trafficking is not limited to youth, either. Yes, Another thing that does not happen as much in the US, but frequently happens with others trying to come to the US. Not being able to afford airfare, boat travel, passports, visas, and so on, the HT victims become indebted to the 'companies' that helped them and agree to 'work it off' or similar. Yes, Many teens who leave an unstable home situation become victims of human trafficking.

Fluid resuscitation for the patient with a major burn is based on a specific formula for the first 24 hours after the burn injury: 4 mL x % of burn X weight (kg). The patient weighs 175 lbs and is burned on 35% of his body. Calculate the hourly fluid rate for the first 8 hours. Round to the nearest whole number._________ mls/hour

Answer: 696

What are potential barriers for the patient during the assessment for domestic violence or human trafficking? Select all that apply A. Fear of being wrong B. Afraid of being judged C. Feeling powerless D. Afraid of making the situation worse E. Feeling shame F. Feelings of deserving of blame G. Independency with money H. Afraid of making an impact or difference in the situation

B. Afraid of being judged C. Feeling powerless D. Afraid of making the situation worse E. Feeling shame F. Feelings of deserving of blame * The nurse is barrier is afraid of being wrong; others barriers for the patient include dependency on money, living space, attention and a sense of not being able to have an impact or make a difference in the situation

Which of the following are potential signs the nurse should recognize as effects of intimate partner violence on work and life? Select all that apply A. Frequent ongoing health care B. Loss of job C. Separate finances and transportation D. Loss of relationships E. Loss of contact with family or friends F. Frequent acute health care

B. Loss of job D. Loss of relationships E. Loss of contact with family or friends *Lack of ongoing health care, finances and transportation controlled to restrict movement and freedom, lack of acute health care

Who is most often the victim of intimate partner violence? A. Married women B. Young men C. Old men D. Young women

D. Young women * more often and younger women between the ages of 18 to 24; abuse include sexual, physical, emotional, financial, etc

What does a 3rd degree burn look like?

Full Thickness Burn; charred, red to white, painless, destroyed skin layer and nerve endings *charring

What does a 4th degree burn look like?

Full Thickness Burn; injury to deeper tissues, such as muscle, tendons, or bone;black *charring

What are some barriers to the nursing assessment for a patient suspected of domestic violence or human trafficking?

Nurse: - Lack of time in interactions - Fearful of saying the wrong thing - fear of offending someone who is not a victim - a sense of not being able to have an impact or make a difference - not sure what to look for - afraid of being wrong - afraid of making the situation worse Patient: - Afraid of being judged - afraid of looking week - afraid of making the situation worse - a sense of not being able to have an impact or make a difference - feeling powerless - feeling shame - feeling deserving of blame - dependency on money, living space, attention

What does a 2nd degree burn look like?

Partial Thickness Burn; Very painful, often BLISTERS, red, moist, weepy skin, skin blanches to touch *blisters

What does a 1st degree burn look like?

Superficial Thickness Burn; top layers reddened, looks like a sunburn; painful, NOT BLISTERED *skin reddened

True or false both men and women experience intimate partner violence

True! It occurs more often in young women; this includes sexual, physical, emotional, financial, etc abuse

Put the following interaction and interview steps in the correct order when speaking to a victim of human trafficking: ____Plan for a short interview that is not too long or draining; have specific questions ready ____Close the interview positively and offer resources. Use close-the-loop communication to identify what will happen next. Validate understanding with client. ____Make contact in a safe space ____Ask non judgmental questions. Listen thoroughly. Use supportive silence. ____During the questioning and listening process, listen and look for signs that the victim feels overwhelmed.

__2__Plan for a short interview that is not too long or draining; have specific questions ready __5__Close the interview positively and offer resources. Use close-the-loop communication to identify what will happen next. Validate understanding with client. __1__Make contact in a safe space __3__Ask non judgmental questions. Listen thoroughly. Use supportive silence. __4__During the questioning and listening process, listen and look for signs that the victim feels overwhelmed. #2. Make sure you pick a good time for the patient to talk. Allow them to reschedule. Limit initial questions to not overwhelm the victim. #5. Thank them for their strength, courage and time. Make sure you tell them they are not to blame. Do not make promises you can't keep, such as "I will fix this". #1. Try to get the victim alone, or approach her in another area that is safe, such as the healthcare system. #3. Stay away from preconceived ideas or blame-laden statements such as "why don't you just leave?" #4. Be prepared to change the subject to give the victim a breather. You can ask about culture, favorite foods, or another less sensitive topic.

What can cause a burn? Match the type of burn with either 1) Drano Max Gel Ultra, 2) Sunlight, 3) Fixing a breaker box 4) House fire ____Thermal ____Chemical ____Radiation ____Electrical

__4__Thermal __1__Chemical __2__Radiation __3__Electrical

Select all the correct interventions for Emergent phase of a burn: a) IV fluid LR b) pain medications c) leave burn open to air d) start multiple IV sites e) start ambulation ASAP to prevent contractures

a) IV fluid LR b) pain medications d) start multiple IV sites

Which states have the highest rate of domestic violence? (select all that apply) a) Texas b) Michigan c) New York d) California e) Texas f) Nevada

a) Texas d) California e) Texas

The nursing supervisor knows that the nurse needs more education if she responds to a domestic violence victim in the ER with... a) What did you do to cause this? b) Do you feels safe at home? c) how is your stress level? d) have you been kicked, hit, punched, or otherwise hurt in the last 6 mos?

a) What did you do to cause this? *places blame on the victim

The nurse is assessing a pt with suspected abuse, what would her findings be? Select all that apply a) avoidance behavior b) smiling c) fingerprint shaped bruises d) malnourished appearance e) well groomed f) frequently apologizes

a) avoidance behavior c) fingerprint shaped bruises d) malnourished appearance f) frequently apologizes

Which of the following alarm the nurse that the pt is declining with an inhalation burn? (select all that apply) a) drooling b) rhonchi c) wheezes d) trouble swallowing e) SOB upon exertion f) changes in speech

a) drooling c) wheezes d) trouble swallowing f) changes in speech

A 30 yr old femal has full thickness burns on the legs & arms. As a nurse, you know this pt is at risk for which of the following? (select all that apply) a) infection b) nutrition imbalance c) electrolyte imbalance d) addison's e) SIADH f) DI

a) infection b) nutrition imbalance c) electrolyte imbalance e) SIADH

The nurse knows which of the following are vunerable populations of domestic violence? Select all that apply a) male b) female c) homeless d) transgender e) elder

a) male b) female c) homeless d) transgender e) elder

Which of the following are good communication techiniques for a pt with suspected human trafficking? (select all that apply) a) paraphrase b) change the subject c) share empathy d) be fully present e) approve client's statements f) supportive silence g) multi-task h) false reassurance

a) paraphrase c) share empathy d) be fully present f) supportive silence

Which assessment findings are most expected during the emergent phase of a burn? (select all that apply) a) tachycardia b) metabolic acidosis c) oliguria d) hypervolemia e) metabolic alkalosis f) hemoconcentration g) pain of 2/10

a) tachycardia b) metabolic acidosis c) oliguria f) hemoconcentration

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.

a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. * Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.

a. Administer the prescribed intravenous morphine sulfate. * Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management.

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.

a. Apply oxygen and continuous pulse oximetry. * Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospitals gift shop. e. Use aseptic technique and wear gloves when performing wound care.

a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. e. Use aseptic technique and wear gloves when performing wound care. *To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the clients room.

A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium

a. Creatinine *Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. b. I will go back to work immediately. c. I will not feel anger about my situation. d. Once I get home, things will be normal.

a. It is normal to feel some depression. * During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a. Keep the water temperature constant when showering the client. b. Assess the wound beds during the hydrotherapy treatment. c. Apply a topical enzyme agent after bathing the client. d. Use sterile saline to irrigate and clean the clients wounds.

a. Keep the water temperature constant when showering the client. * Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile saline.

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control

a. Music as a distraction b. Tactile stimulation e. Increasing client control *Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.

Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? (Select all that apply.) a. Place client in isolation. b. Encourage multiple visitors to support client. c. Ensure that no plants or flowers are in the client's room. d. Teach family members not to bring fresh fruits and vegetables to the client. e. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another.

a. Place client in isolation. c. Ensure that no plants or flowers are in the client's room. d. Teach family members not to bring fresh fruits and vegetables to the client. *Placing the client away from other clients decreases the risk for cross-contamination. Plants, flowers, fruits, and vegetables can have bacteria or fungi that can introduce more contaminants into the environment; these should not be brought to the client's room. The number of visitors and frequency of visits should be limited due to the potential of bringing contaminants into the client's environment. Changing gloves decreases the risk of autocontamination, not cross-contamination.

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.

a. Provide at least 5000 kcal/day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks. *A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time Increased risk for loss of function from contracture formation b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance Increased risk for atelectasis d. High incidence of cardiac impairments Increased risk for acute kidney injury e. Thinner skin May not exhibit a fever when infection is present

a. Slower healing time Increased risk for loss of function from contracture formation c. Reduced thoracic compliance Increased risk for atelectasis d. High incidence of cardiac impairments Increased risk for acute kidney injury *Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.

John arrives to the ER at 6 pm after a MVA at 5:40pm. He sustained burns to his anterior torso & both arms. He weights 150 ibs. Calculate his total fluid resuscitation in the 1st 24 hrs a) 5,515 b) 9,818 c) 14,204 d) 8,905

b) 9,818

The nurse has provided information about a safe shelter for a patient who is the victim of abuse. Which of the following is an additional intervention that the nurse must perform? a) Arrange for transportation to the shelter. b) Report the abuse to the appropriate legal authority. c) Offer paperwork for medical assistance. d) Provide food vouchers for the patient's children.

b) Report the abuse to the appropriate legal authority. *All states have laws for mandatory reporting of suspected cases of abuse; it is not a violation of patient privacy to meet this requirement. Transportation, medical assistance, and emergency food are all helpful interventions, but there are no data indicating that such assistance is needed, and none of these interventions are mandatory.

A new case management nurse has been hired at a nursing home to investigate several recent resident deaths at the facility. The nurse understands that because there are many kinds of potential abuse, she will need to assess for what type of factors? a) High ratio of overweight residents b) Unexplained bruising of residents c) Altered cognitive function of residents d) Skin breakdown in residents resulting from poor hygiene e) Documentation of prescribed physical therapy sessions

b) Unexplained bruising of residents c) Altered cognitive function of residents d) Skin breakdown in residents resulting from poor hygiene *In addition to psychological signs such as depression, signs of elder abuse include bruising from physical abuse and skin breakdown from neglect of hygiene and nutrition; frailty and decreased cognitive function are also risk factors for abuse. Overweight residents and following prescribed treatments are not indicators of abuse or neglect.

A pt with a burn has wheezes assessed in the morning, that disappeared when the nurse reassessed them. What might the nurse do next? a) document & continue to reassess b) contact RT for potential airway edema c) blame the pt for misplacing their wheezes d) give the wheezes back to the pt

b) contact RT for potential airway edema

What topical agent would the nurse expect to be ordered for a pt with electrical burns? a) collagenase b) mafenide acetate c) polymyxln bacltracin d) nitrofurazone

b) mafenide acetate

You have a 15 y/o pt who came into the ER with her dad. They had no proof of insurance or ID. She came in for a pregnancy test, but when you ask her questions only the father answers. What do you do next? a) give her the pregnancy test b) take her to get a urine sample by herself to get more info c) get more info from info from the dad d) give her the results & discharge her

b) take her to get a urine sample by herself to get more info

The nurse is encouraging range-of-motion exercises for the burn client, who states, "this hurts terribly; I don't want to do this." Identify the appropriate nursing response(s). (Select all that apply.) a. "You have to do the exercises to get well." b. "Range-of-motion helps promote mobility." c. "Just visualize a beach to get your mind off of the pain." d. "Let me check when you were last given pain medication." e. "What techniques for pain management have you used in the past that were helpful?" f. "The health care provider has ordered these exercises, and it is important that you do them as instructed."

b. "Range-of-motion helps promote mobility." d. "Let me check when you were last given pain medication." e. "What techniques for pain management have you used in the past that were helpful?" *Range-of-motion exercises should be actively performed at least 3 times daily for best benefit. Pain, or alterations in comfort, can interfere with performance of range-of-motion activities. Be sure the client is properly medicated so that pain medication has time to become effective before performing range-of-motion exercises. Helping the client reflect on pain management techniques that have been successful in the past can be useful. Telling the patient to do the exercises to get well, just to visualize a beach, and that the health care provider ordered the exercises, reflect nontherapeutic responses.

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.

b. Administer furosemide (Lasix) 40 mg IV push. * The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this clients inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the clients body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.

b. Change gloves between wound care on different parts of the clients body. * Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the clients body can prevent autocontamination.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the clients oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the clients intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.

b. Draw blood for a carboxyhemoglobin level. * These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning.

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2 ) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6 F (38 C)

b. Urine output of 20 mL/hr * A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.

A nurse is presenting a workshop on interpersonal violence prevention. Which is a common risk factor for most interpersonal violence incidents that should be addressed? a) Poor working conditions b) Hypertension medications c) Alcohol use d) Poor self-esteem The use or misuse of alcohol is a risk factor in partner violence, child abuse, youth abuse, and elder abuse. Poor working conditions add to stress but would not be a risk factor that most abuse incidents have in common. Hypertension medications do not increase the risk of abusive episodes. Poor self-esteem is not a common risk factor for most abusive episodes.

c) Alcohol use *The use or misuse of alcohol is a risk factor in partner violence, child abuse, youth abuse, and elder abuse. Poor working conditions add to stress but would not be a risk factor that most abuse incidents have in common. Hypertension medications do not increase the risk of abusive episodes. Poor self-esteem is not a common risk factor for most abusive episodes.

A female patient arrives at the emergency department visibly upset and tearful. She refuses to have a male caregiver, asks for a room close to an exit door, and does not make eye contact with staff. What does the nurse suspect is happening with the patient? a) The patient may be having an acute psychotic episode related to her mental illness. b) The patient may be abusing street drugs and needs a drug screening test. c) The patient may have been the victim of an acute assault. d) The patient may be a very demanding and particular person.

c) The patient may have been the victim of an acute assault. *Refusing care from a caregiver of another gender, wanting easy escape access, and having poor eye contact all indicate that an assault may have occurred. Acute psychosis, use of street drugs, or being a demanding person does not elicit the signs of wanting to protect herself from others.

A pt comes to the ED with inhalation burns. What is the priority nursing action? a) administer bicarb b) administer O2 via NC c) administer O2 via non re-breather mask d) start peripheral IV of 0.9%NS at 150 ml/hr

c) administer O2 via non re-breather mask

A nurse uses the rule of ninesto assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? a. 9% b. 18% c. 27% d. 36%

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

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.

c. Auscultate breath sounds over the trachea and bronchi. * Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

c. Forensic nurse examiner *All other members of the health care team listed may be used in the management of this clients care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

A nurse reviews the following data in the chart of a client with burn injuries: 36-year-old female with Bilateral leg burns present with a white and leatherlike appearance, No blisters or bleeding present, NKDA, Health history of asthma and seasonal allergies .Client rates pain 2/10 on a scale of 0- 10. Based on the data provided, how should the nurse categorize this clients injuries? a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial

c. Full thickness 8The characteristics of the clients wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. I will allow my spouse to change my dressings. b. I want to have surgical reconstruction. c. I will bathe and dress before breakfast. d. I have secured the pressure dressings as ordered.

c. I will bathe and dress before breakfast. * Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self- worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? a. You should change the batteries in your smoke detector once a year. b. Join a program that assists burn clients to reintegration into the community. c. I will demonstrate how to change your wound dressing for you and your family. d. Let me tell you about the many options available to you for reconstructive surgery.

c. I will demonstrate how to change your wound dressing for you and your family. * Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond? a. Tagamet stimulates intestinal movement so you can eat more. b. It improves fluid retention, which helps prevent hypovolemic shock. c. It helps prevent stomach ulcers, which are common after burns. d. Tagamet protects the kidney from damage caused by dehydration.

c. It helps prevent stomach ulcers, which are common after burns. * Ulcerative gastrointestinal disease (Curlings ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent

An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the client. c. Listen to the clients concerns and needs. d. Ask security to store the clients belongings.

c. Listen to the clients concerns and needs. *To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the clients belongings and personal space.

After assessing an older adult client with a burn wound, the nurse documents the findings as follows: -Vital Signs: Heart rate: 110 bpm, Blood pressure: 112/68, Respiratory rate: 20, Oxygen saturation: 94%, Pain: 3/10 -Laboratory Results: Red blood cell count: 5,000,000, White blood cell count: 10,000, Platelet count: 200,000 -Wound Assessment: Left chest burn wound, 3 cm 2.5 cm 0.5 cm, wound bed pale, surrounding tissues with edema present Based on the documented data, which action should the nurse take next? a. Assess the clients skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.

c. Prepare to obtain blood and wound cultures. * Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the clients skin should all be implemented but these actions do not take priority over determining whether the client has an infection.

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

c. Provide referrals to subsidized community-based health clinics. *Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L

c. Serum potassium: 6.5 mEq/L * The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero.

c. Sometimes I wake up at night and smoke. * House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140 F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding

A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? a. With reconstructive surgery, you can look the same. b. We can remove the scars with the use of a pressure dressing. c. You will not look exactly the same but cosmetic surgery will help. d. You shouldnt start worrying about your appearance right now.

c. You will not look exactly the same but cosmetic surgery will help. *Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.

The nurse is assessing a 4-year-old child in a health clinic. Which of the following situations would cause the nurse to explore for possible abuse? a) Being brought to the clinic from daycare b) Recent scrapes and bruises on both knees c) The caregiver reporting angry outbursts from the child while they were in a store d) Different explanations of the injury from the child's parents

d) Different explanations of the injury from the child's parents *Inconsistent explanations from parents for how injuries occurred is a cause for further investigation. Being brought in from daycare, school, camp, or other public areas does not automatically indicate abuse. Scrapes on the knees are a common developmental injury for a 4 year old. Angry outbursts or tantrums in children in this age-group are still expected developmental behaviors.

Which of the following respiratory devices would you use if your pt had the following labs: pH: 7.31 PCO2: 55 HCO3: 29 CO2: 29 SaO2: 88% Anion Gap: 25 COHb: 28% a) nasal cannula 6L b) ambubag c) Bipap machine d) Non re-breather mask

d) Non re-breather mask

1. The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? a. "You can see black smoke when carbon monoxide is in the air." b. "If you are experiencing carbon monoxide poisoning, your skin will begin turning blue." c. "The only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire." d. "It is important to have carbon monoxide detectors in your home, because this is an odorless gas."

d. "It is important to have carbon monoxide detectors in your home, because this is an odorless gas." *Carbon monoxide is a colorless, odorless gas; it can be present in environments other than those associated with a fire. Exposure turns skin cherry red. Having carbon monoxide detectors in the home can decrease the likelihood of exposure to this gas, if it is generated as the result of a fire, or as a result of a gas leak from appliances.

Which assessment finding does the nurse interpret as demonstrating a burn client's fluid resuscitation adequacy? a. Decreased skin turgor b. Decreased pulse pressure c. Decreased core body temperature d. Decreased urine specific gravity

d. Decreased urine specific gravity *A decrease in urine-specific gravity indicates that fluid replacement is improving. The higher the urine specific gravity, the higher the indication is of dehydration and inadequacy of fluid resuscitation. Increased—not decreased— skin turgor, pulse pressure, and core body temperature would be associated with fluid resuscitation adequacy.

. A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowlers position. d. Gather appropriate equipment and prepare for an emergency airway.

d. Gather appropriate equipment and prepare for an emergency airway. * Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

d. Place the client in an upright position. *Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the clients wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the clients room.

d. Wash your hands on entering the clients room. * Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.

A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond? a. When the antibiotic therapy is complete. b. As soon as his albumin levels return to normal. c. Once we complete the fluid resuscitation process. d. When all of his burn wounds have closed.

d. When all of his burn wounds have closed. * Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the clients recovery process, they are not as important as skin closure to decrease the clients risk for infection.

An 18 year old female pt admitted for pneumonia has been quiet & withdrawn, often letting her boyfriend speak for her & seems tense when he enters the room. What is your 1st priority action as the nurse? a) assess a full physical assessment to look for bruising/injury b) ask the pt if she is experiencing any SOB & check SpO2 c) ask pt if she feels safe in her relationship when boyfriend leaves the room d) start broad spectrum ATB therapy e) state "you are safe here, I will now assess your lungs"

e) state "you are safe here, I will now assess your lungs"