Chapter 53: Nursing Management: Patients With Burn Injury

Which of the following is to be expected soon after a major burn? Select all that apply. Hypotension Tachycardia Bradycardia Anxiety Hypertension

Hypotension Tachycardia Anxiety Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? Identification by the destruction of the dermis and epidermis Not associated with edema formation Classification by the appearance of blisters Usually very painful because of exposed nerve endings

Identification by the destruction of the dermis and epidermis Explanation: Third-degree (full-thickness) burns involve total destruction of the epidermis and dermis and, in some cases, destruction of underlying tissue. Second-degree burns are associated with blister formation.

A nurse is providing care to a client who has sustained a major burn injury. When developing the client's plan of care, the nurse anticipates that the greatest amount of fluid shifting would occur at which time? approximately 1 week after the burn about 24 hours after the burn 3 to 5 days after the burn not before 48 hours after the burn

about 24 hours after the burn Explanation: In general, the greatest volume of fluid leak occurs in the first 24 to 36 hours after the burn. As the capillaries begin to regain their integrity, burn shock resolves and fluid returns to the vascular compartment. As fluid is reabsorbed from the interstitial tissue into the vascular compartment, blood volume increases.

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include protecting the bed linens and client's clothing from contact to prevent staining. premedicating the client with an analgesic prior to application. monitoring the client for the development of respiratory acidosis. monitoring the client's Na+ and K+ serum levels and replace as prescribed.

premedicating the client with an analgesic prior to application. Explanation: Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the client is an appropriate intervention. The other nursing implications are not associated with mafenide.

During the acute phase of burn injury, the nurse knows to assess for signs of potassium shifting: Between 24 and 48 hours. Within 24 hours. At the beginning of the third day. Beginning on day 4 or day 5.

Beginning on day 4 or day 5. Explanation: Beginning on the fourth or fifth day, potassium shifts from the extracellular fluid into cells, and potassium deficit can occur during this phase.

The nurse is documenting an hourly assessment of a patient who is being treated for full-thickness burns to his lower extremities. Assessment has revealed that the patient's abdominal girth is steadily increasing. This is most likely attributable to what pathophysiological process? Presence of free air under the patient's diaphragm Paralytic ileus Bladder distention due to urinary retention Third spacing

Third spacing Explanation: Fluid shifts into the abdominal cavity causing increased abdominal distention that interferes with pulmonary ventilation. An increase in abdominal girth would be suggestive of third spacing into the peritoneal space. Bladder distention, paralytic ileus, and free air are less likely to cause an increase in abdominal girth.

During the recovery of an extensive burn, the client is uncomfortable wearing the tight-fitting custom garment. Which is the best response by the nurse? "A snug fit is needed to minimize scarring and to smooth the skin." "The garment acts as a skin layer and prevents infection." "Perhaps the garment should be resized." "The garment can be removed for an hour each day."

"A snug fit is needed to minimize scarring and to smooth the skin." Explanation: The forming of burn scars can be minimized by the use of pressure dressings and custom-fitted garments that apply continuous pressure. Garments need to be snug in order to be effective. These garments are worn for 23 hours a day and may be prescribed for as long as 2 years. Prevention of infection is not indicated with use.

A client has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery? Within 24 hours after surgery 2 to 5 days after surgery Within 12 hours after surgery As soon as sanguineous drainage is noted

2 to 5 days after surgery Explanation: The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 30% 27% 36% 18%

36% Explanation: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? 27% 18% 9% 36%

36% Explanation: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area.

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 mL/hr A urinary output of 10 mL/hr

A urinary output of 30 mL/hr Explanation: For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? Hematemesis Diverticulitis Ulcerative colitis Paralytic ileus

Paralytic ileus Explanation: Patients who are critically ill, including those with burns, are predisposed to altered gastrointestinal (GI) motility for many reasons, which may include impaired enteric nerve and smooth muscle function, inflammation, surgery, medications, and impaired tissue perfusion. Three of the most common GI alterations in burn-injured patients are paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and translocation of bacteria. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.

The nurse is caring for a patient who sustained a deep partial-thickness burn injury 36 hours ago. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to which of the following nursing diagnoses? Activity intolerance Acute pain Anxiety Impaired nutrition: less than body requirements

Acute pain Explanation: Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid diagnoses, the presence of pain may contribute to these diagnoses and management of the patient's pain is priority, as it may have a direct correlation to these nursing diagnoses.

The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing? External rotation Dorsiflexion Plantar flexion Adduction

Adduction Explanation: When occlusive dressings are applied, precautions are taken to prevent two body surfaces from touching, such as fingers or toes, ear and scalp, the areas under the breasts, any point of flexion, or between the genital folds.

A client is brought to the emergency department after being involved in a house fire. The client has superficial burns on the arms and legs but emergency medical personnel report that the client may have smoke inhalation. The client is complaining of a headache and some dizziness. The nurse obtains the client's carboxyhemoglobin level which is 15%. Which action by the nurse would be most appropriate? Have the client take slow deep breaths. Give the client a fast-acting bronchodilator. Prepare to intubate the client. Administer 100% oxygen.

Administer 100% oxygen. Explanation: Carbon monoxide (CO) is probably the most common cause of inhalation injury because it is a by-product of the combustion of organic materials and, therefore, is present in smoke. The pathophysiologic effects are caused by tissue hypoxia, a result of carbon monoxide combining with hemoglobin to form carboxyhemoglobin (COHb or HbCO), which competes with oxygen for available hemoglobin-binding sites. The affinity of hemoglobin for carbon monoxide is 250 times greater than that for oxygen. Standard care usually consists of 100% oxygen for 6 hours until the HbCO level is below 10% and the client is asymptomatic.

A patient is recovering from a burn that she experienced 6 weeks earlier. What is a priority in the rehabilitation and predischarge phase of the burn injury? Patient and family education Assessing cardiac output Monitoring fluid and electrolyte imbalances Infection control

Patient and family education Explanation: Patient and family education is a priority in the acute and rehabilitation phases. There should be no fluid and electrolyte imbalances in the rehabilitation phase. Assessing wound healing is an ongoing function, but it is not a priority in the rehabilitation phase. Documenting family support is not a priority in the rehabilitation phase.

A teenage boy has been brought by ambulance to the emergency department from a house fire in which he has suffered extensive injuries. In addition to burns, early blood tests reveal carbon monoxide poisoning. This assessment finding will be treated by what intervention? Deep suctioning Incentive spirometry Administration of 100% oxygen Intubation and administration of bronchodilators

Administration of 100% oxygen Explanation: Treatment for carbon monoxide poisoning usually consists of early intubation and mechanical ventilation with 100% oxygen. Administering 100% oxygen is essential to accelerate the removal of carbon monoxide from the hemoglobin molecule. Bronchodilators, suctioning, and incentive spirometry are ineffective.

Which of the following measures can be used to cool a burn? Wrapping the person in ice Application of cool water Using cold soaks or dressings for at least 1 hour Application of ice directly to burn

Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? Removal of clothing Irrigation of the wound Application of ice Removal of hair

Application of ice Explanation: Application of ice causes vasoconstriction and diminishes needed blood flow to the zone of injury. Clothing and hair are removed from perimeter of burned area in an effort to remove course of bacterial contamination. Irrigation of the wound assists in the removal of debris.

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply. Place the client in a vertical position. Open a door and encourage air in an enclosed space. Place the client in a horizontal position. Roll the client in a blanket to smother the fire.

Place the client in a horizontal position. Roll the client in a blanket to smother the fire. If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? Preexisting conditions Weight Family history Age

Preexisting conditions Explanation: Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn.

Following a burn injury, the nurse determines which area is the priority for nursing assessment? Pulmonary system Cardiovascular system Pain Nutrition

Pulmonary system Explanation: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.

In a client with burns on the legs, which nursing intervention helps prevent contractures? Hyperextending the client's palms Performing shoulder range-of-motion exercises Elevating the foot of the bed Applying knee splints

Applying knee splints Applying knee splints is one method which can help prevent leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs which is the focus for this individual's treatment and care.

Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body? Autograft Allograft Homograft Heterograft

Autograft Explanation: Autografts of full-thickness and pedicle flaps are commonly used for reconstructive surgery months or years after the initial injury. Allografts and homografts are grafts transferred from one human (living or cadaveric) to another human. A heterograft is a graft obtained from an animal of a species other than that of the recipient.

Which of the following terms refers to a graft derived from one part of a patient's body and used on another part of that same patient's body? Allograft Autograft Heterograft Homograft

Autograft Explanation: Full-thickness autografts and pedicle flaps are commonly used for reconstructive surgery, months or years after the initial injury. An allograft is a graft transferred from one human (living or cadaveric) to another human. A homograft is a graft transferred from one human (living or cadaveric) to another human. A heterograft is a graft obtained from an animal of a species other than that of the recipient.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? Ca: 9 mg/dL BUN: 28 mg/dL K+: 5.0 mEq/L Na+: 145 mEq/L

BUN: 28 mg/dL Explanation: The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: Entire dermis and subcutaneous tissue. Epidermis and a portion of deeper dermis. Epidermal layer only. Dermis and connective tissue.

Epidermis and a portion of deeper dermis. Explanation: A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn.

Which type of burn injury requires skin grafting? Full-thickness Superficial Superficial partial-thickness Deep partial-thickness

Full-thickness Explanation: A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? Superficial partial-thickness Superficial Deep partial-thickness Full-thickness

Full-thickness Explanation: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Urine output of 70 ml the first hour Moderate to severe pain Complaints of intense thirst Hoarseness of the voice

Hoarseness of the voice Explanation: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? Heterografts Homografts Autografts Xenografts

Homografts Explanation: Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). An autograft uses the client's own skin, which is transplanted from one part of the body to another.

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. Hourly urine output Percentage of meals eaten Oxygen saturation Skin turgor Daily weights

Hourly urine output Skin turgor Daily weights Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Skin turgor is a sign of fluid loss (dehydration). Percentage of meals eaten, and oxygen saturation would not be reliable indicators of fluid volume status in the client.

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury? Hypokalemia Hypernatremia Hyperkalemia Hypercalcemia

Hyperkalemia Explanation: Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. During burn shock, serum sodium levels vary in response to fluid resuscitation. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. Hyponatremia may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hypoglycemia. Hypocalcemia. Hypernatremia. Hyperkalemia.

Hyperkalemia. Explanation: Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? Apply skin lotion to the area that is burned. Immerse the child in a cool bath. Avoid touching the burned area in any way. Cover the burn with ice and secure with a towel.

Immerse the child in a cool bath. Explanation: After the flames or heat source has been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure and is a priority over not touching the burn. Lotions and ice are not put on the burn.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? Normal saline solution with 20 mEq of potassium per 1,000 ml Lactated Ringer's solution Dextrose 5% in water (D5W) Albumin

Lactated Ringer's solution Explanation: Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? Surgical Natural Chemical Mechanical

Mechanical Explanation: Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic debridement agents are available to promote debridement of the burn wounds. With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tissue.

Acticoat has been ordered as a component of a burn patient's wound care and infection control regimen. When applying this wound care product, the nurse should: Change the dressing every 18 to 24 hours. Use a pad of Acticoat to perform mechanical debridement. Moisten the Acticoat with sterile water and then apply it to the wound bed. Allow the Acticoat to dry thoroughly before covering it with a dry dressing.

Moisten the Acticoat with sterile water and then apply it to the wound bed. Explanation: Acticoat is moistened with sterile water and applied directly to the wound. It is then covered with an absorbent secondary dressing and kept moist. This product is not used for debridement and it can be left in place for 3 to 5 days.

A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? Moisten with saline. Moisten with sterile water only. Keep Acticoat saturated. Use topical antimicrobials with Acticoat burn dressing.

Moisten with sterile water only. Explanation: Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: stasis. coagulation. hypotension. hyperemia.

stasis. Explanation: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. The zone of hypotension is not the name of one of the zones.

Which antimicrobials is not commonly used to treat burns? tetracycline silver nitrate (AgNO3) 0.5% solution silver sulfadiazine (Silvadene) mafenide (Sulfamylon)

tetracycline Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to infection Related to circumferential eschar Related to femoral artery occlusion Related to fat emboli

Related to circumferential eschar As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? Altered Tissue Perfusion Acute Pain Risk for Impaired Gas Exchange Infection Risk

Risk for Impaired Gas Exchange Explanation: During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? Roll the client in a blanket Cover the client with a wet cloth Place the client with the head positioned slightly below the rest of the body Avoid immediate IV fluid therapy

Roll the client in a blanket Explanation: At the scene of a fire, the client should be rolled in a blanket to smother the fire. The client should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

A patient has been prescribed mafenide acetate cream for burn treatment. The nurse should educate the patient regarding which of the following? Blood levels of sodium and potassium will be monitored. Stains clothing Severe burning pain for up to 20 minutes Can be left in place for 3 to 5 days

Severe burning pain for up to 20 minutes Explanation: The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored.

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? Cerium nitrate solution Gentamicin sulfate Sulfadiazine, silver (Silvadene) Mafenide (Sulfamylon)

Sulfadiazine, silver (Silvadene) Explanation: With use of silver sulfadiazine (Silvadene), the nurse should watch for leukopenia 2 to 3 days after initiation of therapy. (Leukopenia usually resolves within 2 to 3 days.) Reference:

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent? Mafenide (Sulfamylon) Cerium nitrate solution Gentamicin sulfate Sulfadiazine, silver (Silvadene)

Sulfadiazine, silver (Silvadene) Explanation: All topical antibacterial agents for burn wounds have associated nursing implications. Leukopenia is a side effect found with Silvadene. Refer to Table 53-5 in the text.

Which of the following is a potential cause of a superficial partial-thickness burn? Scald Electrical current Flash flame Sunburn

Sunburn Explanation: A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? Full-thickness Deep partial-thickness Superficial partial-thickness Superficial

Superficial Explanation: A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? To keep fire and smoke from airway To extinguish flames more quickly To prevent collapse and further injuries To promote blood flow to the brain and vital organs

To keep fire and smoke from airway Explanation: The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. The stop, drop, and roll method is a quick and efficient means to extinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg Rectal temperature of 100.4° F (38° C) Urine output of 20 ml/hour White pulmonary secretions

Urine output of 20 ml/hour A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client? slit graft xenograft autograft allograft

allograft Explanation: Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

The nurse recognizes the first dressing change at the site of an autograft is performed as soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery. as soon as sanguineous drainage is noted. within 24 hours after surgery. within 12 hours after surgery.

as soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery. Explanation: A foul odor or purulent drainage may indicate infection and should be reported to the surgeon immediately. The first dressing change usually occurs 2 to 5 days after surgery. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

A nurse is reading a journal article about the morbidity and mortality associated with burn injury. The nurse demonstrates understanding of the article by identifying which population as having the highest mortality and morbidity rates? older adults young adults children adolescents

older adults Explanation: Morbidity and mortality rates associated with burns are greater in older adults (ABA, 2015) than in the remainder of the population. Thinning and loss of elasticity of the skin predispose them to deep injury from a thermal insult that might cause a less severe burn in a younger person. Furthermore, chronic illnesses decrease the older person's ability to withstand the multisystem stresses imposed by major burn injury.

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: body image. fluid resuscitation. infection. pain management.

pain management. Explanation: With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

The emergency department nurse has just admitted a patient with a burn. The nurse recognizes that the patient is likely to require a nasogastric tube when the burn exceeds a total body surface area (TBSA) of what percentage? 25% 10% 20% 15%

25% Explanation: If the burn exceeds 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction. Often, patients with large burns become nauseated as a result of the gastrointestinal effects of the burn injury, such as paralytic ileus and the effects of medication such as opioids. All patients who are intubated should have a nasogastric tube inserted to decompress the stomach and prevent vomiting.

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 36% 18% 27% 45%

27% Explanation: The TBSA would be 27%. That is 18% of the body surface for the anterior trunk and 9% for the left arm.

The nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching? Select all that apply. A. Wear the garment at least 12 hours each day. B. Contact the primary provider if the garment does not seem to fit properly. C. Machine wash the pressure garment daily with a mild detergent. D. Roll the garment and wring tightly to ensure garment is as dry as possible after washing. E. Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.

B. Contact the primary provider if the garment does not seem to fit properly. E. Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment. When using a pressure garment, the nurse should instruct the client to wear the garment for at least 23 hours a day, not 12 hours a day. The client should contact the primary provider if the garment does not seem to fit. The nurse should instruct the client to hand wash, not machine wash, the pressure garment daily with a mild detergent. The garment should not be wrung dry. Instead, the client should squeeze and roll the garment in a towel to remove as much moisture as possible. The client should also massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.

The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? Electrical burns usually follow an internal path. Lightning is higher in voltage than electricity. The skin is a good conductor of electricity. Moisture intensifies the damage inflicted.

Electrical burns usually follow an internal path. Explanation: Electrical current follows the path of less resistance. Because the skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current.

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of their body. What would be the nurse's priority concern in the immediate care of this patient? Fluid status Body image Risk of infection Anxiety

Fluid status Explanation: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection, body image, and anxiety are significant areas of concern but are less urgent in the short term than fluid status.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? Anemia Cardiac arrest Gastric ulcers Hyperthyroidism

Gastric ulcers Explanation: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? Hemodilution Hemoconcentration Lack of erythropoietin factor Metabolic acidosis

Hemodilution Explanation: Reduced hematocrit is caused by hemodilution 48 hours after a burn, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbuminemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced hematocrit level in this situation. Erythropoietin factor is reduced if kidney failure occurs; however, lack of erythropoietin factor doesn't affect hematocrit level.

Which zone of burn injury sustains the most damage? Inner Middle Protective Outer

Inner Explanation: Each burned area has three zones of injury. The inner area (known as the zone of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.

The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient? Intravenous Intramuscular Subcutaneous Oral

Intravenous Explanation: Intravenous administration is necessary because of altered tissue perfusion from burn injury.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? Mechanical Natural Enzymatic Surgical

Natural Explanation: Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? Cover the client with a wet cloth. Avoid immediate IV fluid therapy. Roll the client in a blanket. Place the client with the head positioned slightly below the rest of the body.

Roll the client in a blanket. Explanation: When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

The open method (exposure method) of burn care, which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale however. On which areas of the body are burns still being treated this way? Select all that apply. The chest The perineum The legs The face

The perineum The face The open method is still being used with the face and the perineum.

he nursing care plan of a patient who is in the acute/immediate phase of burn care identifies a nursing diagnosis of Risk for Infection due to burns. What intervention should be prioritized in response to this diagnosis? Administration of oral prophylactic antibiotics Intravenous administration of broad-spectrum, prophylactic antibiotics Vigilant application of infection-control precautions such as gloves, gowns, and masks Regular disinfecting of the patient's intact skin and the immediate bedside environment

Vigilant application of infection-control precautions such as gloves, gowns, and masks Explanation: Infection control is a major role of the burn team in providing wound care. Cap, gown, mask, and gloves are worn while caring for the patient with open burn wounds. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. Disinfectants are not applied to the patient's intact skin.

The emergency department (ED) team is conducting immediate care of a patient admitted with burns estimated at 40% total body surface area. The nurse in the ED and the other members of the team are aware of the need to customize the rate of fluid resuscitation and will base this rate on what data? Vital signs and urine output Arterial blood gases and breath sounds Level of consciousness and pain levels Abdominal girth measurements and abdominal tone

Vital signs and urine output Explanation: Because of the risks associated with invasive monitoring, traditional variables of hourly assessment of urinary output and vital signs are used to evaluate the adequacy of fluid replacement therapy in burn patient. Reference:

As the first priority of care, a patient with a burn injury will initially need: pain medication administered. fluids replaced. an indwelling catheter inserted. a patent airway established.

a patent airway established. Explanation: Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen.

The nurse is reviewing the admission blood work of a patient who is being treated for significant burns. The patient's serum potassium level is 7.1 mEq/L (normal 3.5 to 5.0 mEq/L), which is primarily a result of: Massive adrenal release of glucocorticoids Cell destruction Myocardial stress Acute renal failure

Cell destruction Explanation: Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. This electrolyte imbalance is not a consequence of acute renal failure, myocardial damage, or corticosteroid release.

What quick assessment technique should the nurse use to assess the percentage of burn injury? Compare the client's palm with the size of the burn wound Observe the color of the client's wound Observe the client's level of consciousness Check the client's vital signs

Compare the client's palm with the size of the burn wound Explanation: A quick technique to assess the percentage of burn injury is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's total body surface area. Observing the color of the client's wound, checking the client's vital signs, and observing the client's level of consciousness determine the client's health status but do not help assess the percentage of burn injury.

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? "Are the victims suffering from thermal burns?" "Are the burns associated with chemicals used in the plant?" "Are any of the victims expected to have electrical burns?" "How many victims are anticipated for transport?"

"Are the burns associated with chemicals used in the plant?" Explanation: If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel.

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? "I will drink a lot of fluids to prevent constipation since I am taking pain medications." "I can work with the social worker to find funding assistance programs to help with my medical expenses." "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun."

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." Explanation: Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated. The other statements indicate that teaching has been effective.

A patient has entered the rehabilitative stage of burn treatment and is now receiving extensive health education in preparation for discharge. The patient's plan of care involves the use of elastic pressure garments. What teaching should the nurse provide to the patient about this intervention? "Your pressure garments will be most effective if you wear them in a cycle of 2 hours on, 2 hours off." "It's important that you try to keep your pressure garments in place at all times." "Scarring will be best controlled if you remove your pressure garments for 3 to 4 hours each day." "You should plan to wear your pressure garments for 24 hours a day, 5 to 6 days a week."

"It's important that you try to keep your pressure garments in place at all times." Explanation: To prevent scarring, pressure garments should be worn continuously.

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? 1,200 mL 2,400 mL 3,600 mL 4,800 mL

2,400 mL Explanation: The ABA consensus formula provides for the volume of an isotonic solution (e.g., lactated Ringer's [LR]) to be administered during the first 24 hours in a range of 2 mL/kg/percentage TBSA. Half of the calculated total should be given over the first 8 postburn hours, and the other half should be given over the next 16 hours. Thus, the equation to find the minimum amount to infuse for this scenario is as follows: 2 mL × 80 kg × 30 = 4,800 mL of solution to be administered in the first 24 hours, with half this amount, 2,400 mL, to be administered in the first 8 hours.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? 27% 36% 9% 18%

27% Explanation: 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 his back (18%) and one arm (9%), totaling 27% of his body.

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? Superficial partial thickness Full-thickness Deep partial-thickness Fourth degree

Deep partial-thickness Explanation: A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis as well as injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.

A patient has been admitted to the burn unit at a large, tertiary care hospital with burns that involve 35% of the patient's total body surface area (TBSA). The nurse on the burn unit should be aware that: Burns involving a large TBSA are often less painful than burns that are less extensive. Extensive burns have pathophysiological effects that supersede the integumentary system. Extensive burns necessitate palliative care rather than curative treatments. Burns that involve a large TBSA are always accompanied by sepsis.

Extensive burns have pathophysiological effects that supersede the integumentary system. Explanation: Burns that exceed 25% TBSA may produce a local and a systemic response and are considered major burn injuries. Pain is roughly commensurate with the extent of injury. Sepsis is a constant risk, but it is not an inevitability. Palliative care is not always necessary, though it is a possibility.

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client Fluid resuscitation Strict intake and output Endotracheal tube placement Prevent infection

Fluid resuscitation Explanation: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.

A critical care nurse frequently provides care on the burns and plastics unit of the hospital. When providing care for patients with recent, extensive burns, the nurse will need to be aware of which cardiovascular alteration that occurs with extensive burns? Decreased erythropoiesis Fluid shifting into interstitial spaces Increased hemolysis by the spleen Sequestering of fluid in the capillaries

Fluid shifting into interstitial spaces Explanation: Extensive burns are accompanied by hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This leaky capillary syndrome increases cell permeability at the burn site as well as throughout the body. Erythropoiesis and hemolysis are affected, but these phenomena do not account for the profound hemodynamic changes that accompany burns.

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of their body. What would be the nurse's priority concern in the immediate care of this patient? Risk of infection Body image Anxiety Fluid status

Fluid status Explanation: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection, body image, and anxiety are significant areas of concern but are less urgent in the short term than fluid status.

A male patient is brought to the emergency department (ED) from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When the nurse assesses the patient, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's right arm? Superficial partial-thickness Deep partial-thickness Full partial-thickness Full-thickness

Full-thickness Explanation: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Full partial-thickness is not a depth of burn. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis, and the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis and the patient will complain of pain and sensitivity to cold air.

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. Remove his burned pants so that the air can help cool the wound. Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area.

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. Explanation: After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process.

The nurse's hourly assessment of a male patient with burns reveals that the patient's blood pressure is trending downward and that his heart rate is trending upward. What intervention has the potential to resolve these trends? Increasing the rate of the patient's fluid resuscitation Performing intermittent urinary catheterization Increasing the rate of the patient's morphine infusion Repositioning the patient

Increasing the rate of the patient's fluid resuscitation Explanation: Low blood pressure and increased heart rate may indicate hypovolemic shock, a problem that may be addressed by measures that include increasing the rate of the patient's fluid resuscitation.

A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort? Apply warm compresses over the areas. Instruct to pat and not scratch the areas. Elevate the extremities above heart level. Provide pain medication as needed.

Instruct to pat and not scratch the areas. Explanation: Post-burn pruritus (itching) affects almost all clients with burns and is one of the most distressing symptoms in the post-burn period. The client should be instructed to "pat, don't scratch" in order to prevent further discomfort and infectious complications. Other actions to reduce the itching include oral antipruritic agents, environmental conditions, frequent lubrication of the skin with water or silica-based lotion, and diversion activities. Warm compresses will enhance the itching. Elevating the extremities above the level of the heart helps reduce edema. Pain medication is not used to treat pruritis.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. Do nothing until the chemical agent is identified. Irrigate the wounds with water. Wash the wounds with soap and water and apply a barrier cream.

Irrigate the wounds with water. Explanation: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

A patient has just been admitted after experiencing severe burns in an automobile accident. What intravenous solution should the nurse anticipate administering during this patient's immediate care? 5% dextrose with 0.45% saline D5½NS) 5% dextrose with sterile water (D5W) Lactated Ringer's Normal saline

Lactated Ringer's Explanation: Lactated Ringer's (LR) is the preferred intravenous fluid for burn resuscitation, because the sodium concentration (130 mEq/L) and potassium (4 mEq/L) are similar to normal intravascular levels (sodium of 135 to 145 mEq/L and K+ of 3.5 to 5 mEq/L).

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? Music therapy diverts the client's attention toward painful stimulus. Humor therapy has not proven effective in the management of burn pain. Music therapy may provide reality orientation, distraction, and sensory stimulation. Pet therapy has proven effective in the management of burn pain.

Music therapy may provide reality orientation, distraction, and sensory stimulation. Explanation: Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the client's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It allows for client self-expression. Humor therapy has proven effective in the management of burn pain. Pet therapy has not proven effective in the management of burn pain.

A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested? Face and neck Neck and chest Face, neck, and chest Face only

Neck and chest Explanation: Skin grafting is essential for deep partial-thickness burns on the client's neck and chest because the skin layers responsible for regeneration have been destroyed. The client's face does not need skin grafting because the burns are superficial and will heal unassisted.

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? The client has experienced partial-thickness burns. The paramedic administered high doses of opioids during transport. The client has experienced extensive full-thickness burns. The client is in hypovolemic shock.

The client has experienced extensive full-thickness burns. Explanation: In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? The client's heart rate is rapid. The client is conscious. The client's urinary output is 0.5 mL/kg/hour. The client's breathing is unlabored and skin is clammy.

The client's urinary output is 0.5 mL/kg/hour. Explanation: Successful fluid resuscitation is gauged by a urinary output of 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? The client's urinary output is 0.5 to 1 mL/kg/hour. The client is alert and conscious. The client's heart rate is rapid and regular. The client's breathing is unlabored, and skin is clammy.

The client's urinary output is 0.5 to 1 mL/kg/hour. Explanation: Successful fluid resuscitation is gauged by a urinary output of 0.5 to 1 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? The early appearance of the burn injury may change. The wound is susceptible to infections. The client's condition is likely to deteriorate after 72 hours. It helps determine the percentage of the total body surface area (TBSA) that is burned.

The early appearance of the burn injury may change. Explanation: The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours.

The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply. Covers face with a scarf Wears hats and wigs Reports absence of sleep disturbance Participates actively in daily activities

Wears hats and wigs Participates actively in daily activities The following are indicators that a client is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the client is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured client but is not related to body image disturbance.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. increase skeletal muscle breakdown. increase glucose demands. increase metabolic rate.

decrease catabolism. Explanation: The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote increased skeletal muscle breakdown. increased metabolic rate. increased glucose demands. decreased catabolism.

decreased catabolism. Explanation: Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

A nurse suspects that a client with a severe burn injury may be developing abdominal compartment syndrome. Which intervention would the nurse anticipate being used to confirm this suspicion? central venous pressure monitoring telemetry intra-bladder pressure monitoring intra-arterial pressure monitoring

intra-bladder pressure monitoring Explanation: To assess for the development of abdominal compartment syndrome, the intra-bladder pressure may be monitored. The other types of monitoring would not be used to determine abdominal compartment syndrome.

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. How would the nurse document the depth of burn injury this client has? superficial (first degree) full thickness (third degree) fourth degree superficial partial-thickness or deep partial-thickness (second degree)

full thickness (third degree) Explanation: Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appearance varies and can be dry, pale white, red, brown, leathery, charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? intravascular fluid excess hypertension neuroendocrine inflammatory

inflammatory Explanation: The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.