Med Surg 2: Test 5 Burns/medical emergencies Prepu

A parent of a toddler brings the child to the emergency department because the child has accidentally been scalded by hot water spilling from the stove. In order to differentiate the burn from potential abuse, the nurse first should assess the child: A. on the back of the body. B. on the front of the body. C. for a circular pattern. D. on the buttocks.

B. on the front of the body. Accidental scaldings are usually splash-related and occur on the front of the body. Any burns on the back of the body or in a well-defined circular or glove pattern may indicate physical abuse. Immersion burns on the buttocks are also suspicious injuries.

A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which treatment is most likely appropriate in the immediate treatment of the girl's poisoning? A. Administration of activated charcoal B. Inducing vomiting C. Gastric lavage D. Intravenous rehydration

A. Administration of activated charcoal Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl's poisoning.

The nurse is assessing an older adult who is living with his son's family. The client has scald burns on the hands and both forearms (10% first- and second-degree burns). The nurse should first: A. Cleanse the wounds with warm water. B. Apply antibiotic cream. C. Call for transport to a hospital. D. Cover the burns with sterile dressing.

C. Call for transport to a hospital. The nurse has the client transported to a hospital. The client's age and the extent of the burns require care by a health care team. Additionally, the nurse considers that the client may be a victim of elder abuse and investigates further as needed. The nurse should refrain from cleansing the wound, applying cream, or covering the area.

Skin grafts are necessary for which of the following burns? A.Superficial B. Superficial partial thickness C. Full-thickness D. First degree

C. Full-thickness Skin grafts are necessary for a full-thickness burn because the skin cells no longer are alive to regenerate. Superficial (first degree), superficial partial-thickness burns do not usually need skin grafting.

The nurse is caring for a child with burn injury who has been admitted to the acute care facility. When assessing this child, which metabolic changes would the nurse expect to find? Select all that apply. A. Hypermetabolism B. Elevated catecholamines C. Hyperglycemia D. Protein excess E. Positive nitrogen

A. Hypermetabolism B. Elevated catecholamines C. Hyperglycemia Hypermetabolism, elevated catecholamine levels, hyperglycemia, and increased nutritional needs due to protein deficits and negative nitrogen balance are metabolic changes associated with pediatric burns.

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns? A. deep tissue cooling B. continuing inflammatory process C. protein cell coagulation D.All options are correct.

A. deep tissue cooling Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.

When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure? A. Respiratory alkalosis B. Myocardial depression C. Rapid, shallow respirations D. Lethargy and confusion

B. Myocardial depression The body's inability to meet increased oxygen requirements produces ischemia, and biochemical mediators cause myocardial depression. This leads to failure of the cardiac pump, even if the underlying cause of the shock is not of cardiac origin.

When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? A. Deep partial thickness B. Superficial partial thickness C. Full thickness D. Superficial

A. Deep partial thickness A deep, partial-thickness burn is similar to a second-degree burn and is associated with scalds and flash flames. Superficial partial thickness burns are similar to first-degree burns and are associated with sunburns. Full thickness burns are similar to third-degree burns and are associated with direct flame, electric current, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.

Which type of burn is similar to a sunburn? A. Superficial partial-thickness B. Electrical C. Deep partial-thickness D. Full-thickness

A. Superficial partial-thickness A superficial partial-thickness burn is similar to a sunburn. Deep partial thickness burns may need debridement and may scar. Full-thickness burns destroy all layers of the skin and consequently are painless. Electrical burns are a type of burn but not a category of burn thickness.

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock? A. Weak and rapid pulse rate B. Warm, dry skin C. Pooling of secretions in the lungs D. Obstructed airway

A. Weak and rapid pulse rate Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.

A client who is suffering a myocardial infarction is transported to the ED by ambulance. This client is at greatest risk for developing which type of shock? A. cardiogenic shock B. obstructive shock C. distributive shock D. hypovolemic shock

A. cardiogenic shock Cardiogenic shock is caused by decreased force of ventricular contraction. Both myocardial infarction and cardiac dysrhythmia may cause cardiogenic shock. Obstructive shock is characterized by an impaired filling of heart with blood due to mechanical impediment, such as cardiac tamponade, dissecting aneurysm, or tension pneumothorax. Disruptive shock is caused by the enlargement of the vascular compartment and redistribution of intravascular fluid from arterial circulation to venous or capillary areas. Hypovolemic shock is caused by decreased blood volume with decreased filling of the circulatory system. Typical examples are hemorrhage, extreme dieresis, and third-spacing.

A client is receiving sulfonamide cream as topical treatment for burns. When reviewing the daily laboratory tests, the nurse notices that the client's white blood cell (WBC) count has decreased. The nurse reviews the data and determines that: A. tt is normal to have this response from immunosuppression. B. this is normal; an increased WBC would be a concern. C. this is abnormal; the health care provider needs to be alerted. D. the WBC count should be observed over several days to look for a trend.

C. this is abnormal; the health care provider needs to be alerted. Leukopenia, or a decreased WBC count, is an adverse reaction to sulfonamide cream. A decreased WBC count should be reported to the health care provider immediately. Sulfonamide cream should be discontinued until WBC count returns to normal.

The nurse is caring for a child who was injured in a bike accident. The nurse determines that a child is experiencing late signs of increased intracranial pressure based on which assessment findings? Select all that apply. A. Bradycardia B. Fixed dilated pupils C. Irregular respirations D. Increased blood pressure E. Sunset eyes

A. Bradycardia B. Fixed dilated pupils C. Irregular respirations Late signs of increased intracranial pressure include bradycardia, fixed and dilated pupils, and irregular respirations. Increased blood pressure and sunset eyes are early signs of increased intracranial pressure.

Following an explosion at a chemical plant, a nurse is triaging clients. One client has a penetrating abdominal wound from a piece of shrapnel. What color coordinate would the nurse assign to this client? A. yellow B. red C. green D. black

A. yellow A yellow triage tag means the client is in serious condition yet stable enough to survive if treatment is delayed 6 to 8 hours. Red tags are assigned to life-threatening injuries that require immediate medical attention. Green tags indicate the client has minor injuries, such as minor lacerations or superficial burns. Black tags indicate the client is going to die soon and usually apply to serious head injuries or multisystem traumas.

En route to the ED, a client's systolic BP was 98 mm Hg and sinking. Which systolic BP supports the diagnosis of shock? Select all that apply. A. 80 mm Hg B. 75 mm Hg C. 72 mm Hg D. 95 mm Hg E. 86 mm Hg

A. 80 mm Hg B. 75 mm Hg C. 72 mm Hg For a normotensive adult, average systolic BP is 120 mm Hg. Therefore, a systolic BP of 90 to 100 mm Hg indicates impending shock, whereas 80 mm Hg or below indicates shock.

The nurse is preparing to give an educational program to parents of toddlers related to promotion of safety. What should the nurse discuss with parents to reduce the risk of injury for this developmental stage? Select all that apply. A. Falls from stairs B. Accidental drowning C. Electrocution from outlets D. Play-related injuries E. Ingestion of toxic medicine

A. Falls from stairs B. Accidental drowning C. Electrocution from outlets Infants and toddlers are vulnerable and often the victims of accidental poisoning, falls from stairs or high chairs, burns, electrocution from exploring outlets or manipulating electric cords, and drowning. Infants and toddlers are not at the highest risk of play-related injuries or ingestion of toxic medicine. Young children are at the highest risk of play-related injuries; older adults are at the highest risk of fatigue and ingestion of toxic medicines, not infants and toddlers.

A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool? A. Rule of nines B. Lund and Browder method C. Hand method D. Parkland formula method

B. Lund and Browder method The Lund and Browder method divides the body into smaller segments. Different percentages are assigned to body parts, depending on patient's age. For example, the adult head is equivalent to 9%,whereas the infant head is 19%. This method is more accurate when dealing with children. The rule of nines and hand method are quick assessment techniques for estimating burns. The Parkland formula incorporates fluid resuscitation requirements for burns.

The nurse is monitoring the intake and output of a client with deep partial-thickness or second-degree burns. The child weighs 75 lb (34 kg). The nurse will contact the physician if the child's urine output drops below how many milliliters per hour? (Round you answer to the nearest whole number.)

34 The child with burns should have a urine output of at least at least 1 mL/kg/hour. The calculations for this scenario are: 1 mL X 34 kg= 34 mL/hour

The nurse on the burn unit is caring for an adolescent with burns to the face and anterior neck, anterior chest, bilateral arms circumferentially, and the right anterior leg. Based on the Rule of Nines, calculate the body surface area that is burned. Record your answer using one decimal place. Rule of Nines Surface area Anterior head 4.5% Posterior head 4.5% Anterior torso 18% Posterior torso 18% Anterior leg, each 9% Posterior leg, each 9% Anterior arm, each 4.5% Posterior arm, each 4.5% Genitalia/perineum 1%

49.5 The Rule of Nines is the standard for estimating total body surface area burned. To calculate: anterior head = 4.5% anterior chest (torso) = 18% both arms anterior and posterior - 9% each = 18% anterior right leg = 9% Total = 49.5%

A nurse is working as part of a response team caring for children who have been involved in an elementary school fire. Which children would the nurse identify as needing a referral to a burn unit? Select all that apply. A. 8-year-old with an inhalation injury B. 6-year-old with burns involving the knees and hips C. 10-year-old with partial-thickness or second-degree burns over 15% of the body D. 9-year-old with asthma and burns to the face E. 7-year-old with superficial or first-degree burns over 5% of the body

A. 8-year-old with an inhalation injury B. 6-year-old with burns involving the knees and hips C. 10-year-old with partial-thickness or second-degree burns over 15% of the body D. 9-year-old with asthma and burns to the face Referral to a burn unit should occur for children with inhalation injuries, burns that involve the face, the hands and feet, genitalia, perineum, or major joints; partial-thickness or second-degree burns greater than 10% of total body surface; burns and preexisting conditions that might affect the care (such as asthma), or burns and traumatic injuries such as rib fractures. Superficial or first-degree burns over 5% of the body are not a criterion for referring a child to a burn unit.

The nurse is preparing an assessment guide for the emergency department staff regarding assessment of clients are admitted with burn injuries. What should the nurse be sure to include in the assessment guide for primary emergency assessment of burns? A. Airway assessment B. Depth of the burn/s C. Presence of edema D. Percentage of body burned E. Pulse strength

A. Airway assessment C. Presence of edema E. Pulse strength The primary survey includes evaluation of the child's airway, breathing, and circulation. The secondary survey focuses on evaluation of the burns and other injuries.

The process of removing necrotic tissue in the treatment of burns is known as: A. Debridement B. Hydrotherapy C. Autograft D. Allograft

A. Debridement Debridement (removal of necrotic tissue), usually preceded by hydrotherapy (use of water in treatment), is performed in the treatment of burns. Debridement is extremely painful, and the child must have an analgesic administered before the therapy.

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. A. systolic blood pressure B. urine output C. breath sounds D. cerebral perfusion pressure E. level of pain

A. systolic blood pressure D. cerebral perfusion pressure The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.

The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? A. Serum thyroid level findings B. Arterial blood gas (ABG) findings C. Red blood cells (RBCs) and hemoglobin count findings D. White blood cell count findings

B. Arterial blood gas (ABG) findings Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Serum thyroid level findings do not help determine the presence of hypoxemia or metabolic acidosis.

The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. A. Vomiting B. Burns C. Diarrhea D. Dehydration E. Trauma

B. Burns D. Dehydration The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.

The emergency nurse is performing an assessment on a client who experienced second and third degree burns of the arms and hands from a kitchen grease fire. Which assessment should be performed first? A. Details of the incident. B. Breathing status and lung sounds. C. Extensiveness and depth of the burns. D. Blood pressure and heart rate

D. Blood pressure and heart rate When a client is burned, breathing should be the first concern if the client may have experienced an inhalation injury. Since this client did not, circulation and perfusion become the greatest concern which are assessed with blood pressure and heart rate. Skin assessment of the burns is important after circulation is stabilized. Information about the detail of the incident are not a priority.

Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern? A. Zone in burn center B. Zone of coagulation C. Zone of hyperemia D. Zone of stasis

D. Zone of stasis The zone of stasis lies outside the burn center and zone of coagulation. This is where the blood vessels are damaged, but tissue has the potential to survive with proper management. The center zone or zone of coagulation is the deepest area of injury and is considered the zone of irreversible damage, placing the focus on saving the surrounding tissues. The zone of hyperemia is the area of least injury.

What important assessment data will help the nurse ensure accurate fluid replacement for a client with burns? A. Vital signs and presence of edema B. Age, weight, vital signs, and tissue turgor C. Urine output, mucous membrane hydration, and orientation D. Capillary refill, specific gravity of urine, and blood pressure readings

B. Age, weight, vital signs, and tissue turgor Considering the client's physiologic status by age and weight is important in determining the fluid requirements. Assessing the amount of damage to skin and mucus membranes is also important because fluid will extravasate into the burned tissue. Monitoring vital signs and tissue turgor levels will also help indicate how the client's body is compensating. The remaining answers are secondary in importance to ensuring airway patency.

The nurse is caring for a teenage client on a burn unit who has sustained third-degree burns over 40% of the body. A family member asks why the client isn't reporting of more pain. Which of the following is the best response by the nurse? A. "The pain medication is working adequately." B. "The client is confused and can't verbalize a pain rating." C."The severe burns have damaged nerves that sense pain." D. "The burns are not deep enough to cause much pain."

C. "The severe burns have damaged nerves that sense pain." Full-thickness burns damage nerve endings and initially may feel somewhat painless. Regeneration of the nerve endings in recovery may cause significant pain. Confusion, adequate pain medication, and burns that are not deep enough would not be the most likely explanation of the client's lack of reports of pain.

A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of A. pulmonary edema. B. hypothermia. C. hyponatremia. D. head injury.

A. pulmonary edema. Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and therefore an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The client would experience hypernatremia. Hypothermia and head injury may be associated with near drowning but would be apparent at the time of admission and would not develop after several hours.

Which clinical manifestation would lead the nurse to suspect an infant has hydrocephaly? Select all that apply. A. depressed fontanel B. headache C. vomiting D. low pitched cry E. irritability F. pupillary changes G. bulging fontanel

C. vomiting E. irritability F. pupillary changes G. bulging fontanel Hydrocephaly is a block in the flow of cerebral spinal fluid. Hydrocephaly results in increased intracranial pressure (ICP). Vomiting, irritability, bulging fontanel, and pupillary changes are all signs of increased intracranial pressure in an infant. A depressed fontanel could be an indication of dehydration, not increased intracranial pressure. A headache may be present in an infant with increased ICP; however, the infant has no way of communicating this to the nurse or parent. A headache is an indication of increased ICP in a verbal child. A high-pitched cry is indicative of infants with increased intracranial pressure.

An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply. A. the victim with chemical spills on both arms B. the victim with third-degree burns of both legs C. the victim with first-degree burns of both hands D. the victim in respiratory distress E. the victim who inhaled smoke

A. the victim with chemical spills on both arms B. the victim with third-degree burns of both legs D.the victim in respiratory distress E .the victim who inhaled smoke Victims with chemical burns, second- and third-degree burns over more than 20% of their body surface area, and those with inhalation injuries should be transported to a burn center. The victim with first-degree burns of the hands can be treated with first aid on the scene and referred to a health care facility.

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

C. Compare the client's palm with the size of the burn wound 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 nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in teaching parents about how to protect a toddler from accidental poisoning? A. Closely monitor the toddler's activity. B. Label poisonous solutions. C. Keep cleaning solutions locked up. D. Do not leave the toddler alone.

C. Keep cleaning solutions locked up. The parents should keep cleaning solutions locked up to protect the toddler from accidental poisoning. Accidental poisonings usually occur among toddlers and commonly involve substances located in bathrooms or kitchens. Labeling poisonous substances may not help as toddlers are unable to read. Not leaving the child alone and closely monitoring the child are important, but not feasible all the time.

A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, his vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply. A. Cleaning the burns with hydrogen peroxide B. Covering the burns with saline-soaked towels C. Starting an I.V. infusion of lactated Ringer's solution D. Placing ice directly on the burn areas E. Administering 6 mg of morphine I.V. F. Administering tetanus prophylaxis as ordered

C. Starting an I.V. infusion of lactated Ringer's solution E. Administering 6 mg of morphine I.V. F. Administering tetanus prophylaxis as ordered The goal of immediate interventions for this client should be to stop the burning and relieve the pain. To prevent hypovolemic shock and maintain cardiac output, the nurse should begin I.V. therapy with a crystalloid such as lactated Ringer's solution. To treat pain, she should administer 2 to 25 mg of morphine or 5 to 15 mg of meperidine I.V. in small increments. The nurse should also administer tetanus prophylaxis as ordered. Hydrogen peroxide and povidone-iodine solution could cause further damage to tissue, and saline-soaked towels could lead to hypothermia. Placing ice directly on burn wounds could cause further thermal damage.

An infant with increased intracranial pressure (ICP) on a regular diet vomits while eating dinner. What should the nurse do next? A. Put the child on nothing-by-mouth (NPO) status for 4 hours. B. Call to report this event to the health care provider (HCP). C. Wait a few minutes, and then refeed the child. D. Administer the prescribed antiemetic.

C. Wait a few minutes, and then refeed the child. Increased ICP can cause vomiting, particularly in children whose fontanels are closed. An infant with an open anterior fontanelle may have less vomiting because the cranium can respond, expanding with increased ICP. The best course of action is to wait a few minutes and then refeed the child. Putting the child on NPO status may not be helpful because this is not a gastrointestinal problem. Because this is an expected event, notifying the health care provider (HCP) is not necessary. Antiemetics frequently make a client sleepy, making neurologic checks difficult to interpret.

Which statement should the nurse include in the teaching plan for a family that is learning about fire safety? A. "Cigarette smoking is no longer a major cause of home fires because most people smoke outside." B. "Electric heaters are safer and do not usually increase the risk of fire in the home." C. "Most fires occur outside of the home when grilling out or camping." D. "Most people who die in home fires die from inhalation and not from burns."

D. "Most people who die in home fires die from inhalation and not from burns." Most people who die in home fires die from inhalation and not from burns. Cigarette smoking is a common cause of house fires when people fall asleep in a chair or bed while smoking. Electric heaters can also be a risk for fires in the home, and most fires occur inside the home.

Which of the following is a common complication of an electrical burn injury? A. Localized edema B. Absent bowel sounds C. Loss of mobility D. Cardiac dysrhythmias

D. Cardiac dysrhythmias Cardiac dysrhythmias and central nervous system complications are common among victims of electrical burns; localized edema, absent bowel sounds, and loss of mobility are not.

A nurse is assessing a 3-year-old child who has ingested toilet bowl cleaner. What finding should the nurse expect? A. Reddish colored skin B. Edematous lips C. Hypertension D. Lower abdominal pain

B. Edematous lips A child who has ingested a caustic poison such as lye (found in toilet bowl cleaners) may develop edema, ulcers of the lips and mouth, pain in the mouth and throat, excessive salivation, dysphagia, and burns of the mouth, lips, esophagus, and stomach. Bleeding from burns in the GI tract can lead to pallor, hypotension (not hypertension), tachypnea, and tachycardia. The nurse would not expect to find reddish colored skin and lower abdominal pain because they don't commonly occur in caustic poisoning.

A parent brings her 3-month-old child into the emergency department. The child is listless with dry mucous membranes, tenting of the skin on the forehead, a depressed fontanel, and a history of vomiting and diarrhea for the last 36 hours. In what order from first to last should the nurse implement the primary care provider's prescriptions? All options must be used. 1. Apply a urine collection bag. 2. Obtain vital signs and weight. 3. Draw blood for laboratory tests. 4. Insert an IV and infuse fluids as prescribed.

2. Obtain vital signs and weight. 1. Apply a urine collection bag. 4. Insert an IV and infuse fluids as prescribed. 3. Draw blood for laboratory tests. The nurse should first obtain vital signs and evaluate the child for signs of shock or cardiac arrhythmias. The weight can also be obtained at this time to estimate the amount of fluid lost. The nurse should next apply the urine collection bag. As soon as possible after these steps, the nurse should insert an IV to replace lost fluids, electrolytes, and sugar to reduce the incidence of metabolic acidosis created by the lack of calorie intake and the loss of electrolytes. Blood should be drawn to assess the severity of electrolyte imbalance and other possible causes for the diarrhea and vomiting.

A patient has had a large ischemic stroke and is hospitalized in the neurologic intensive care unit. What interventions will be provided for this patient to decrease intracranial pressure? Select all that apply. A. Administering mannitol B. Maintaining the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 35 mm Hg C. Administering heparin to induce anticoagulation D. Administering supplemental oxygen if the oxygen saturation is below 88% E. Elevating the head of the bed 30 degrees

A. Administering mannitol B. Maintaining the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 35 mm Hg E. Elevating the head of the bed 30 degrees Increased intracranial pressure (ICP) from brain edema and associated complications may occur after a large ischemic stroke. Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol), and maintaining the partial pressure of arterial carbon dioxide (PaCO2) within a slightly lower range of 30 to 35 mm Hg. The nurse should provide supplemental oxygen if oxygen saturation is below 92%, not below 88%. The head of the bed should be elevated to 25 to 30 degrees to assist the patient in handling oral secretions and decrease intracranial pressure. Because of the risks associated with anticoagulants (such as heparin), their general use is no longer recommended for patients with acute ischemic stroke.

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. A. Administering prescribed antipyretics B. Elevating the head of the bed to 90 degrees C. Maintaining aseptic technique with an intraventricular catheter D. Encouraging deep breathing and coughing every 2 hours E. Frequent oral care

A. Administering prescribed antipyretics C. Maintaining aseptic technique with an intraventricular catheter E. Frequent oral care Controlling fever is an important intervention for a client with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate to control a fever. It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection. Oral care should be provided frequently because the client is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used. Coughing should be discouraged in a client with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated to 30 to 45 degrees and in a neutral position to allow for venous drainage.

Which clients would be appropriate candidates for total parenteral nutrition? Select all that apply. A. Client who has second- and third-degree (partial- or full-thickness) burns over 40% of the body B. A client with peptic ulcer disease C. Client who had gastric surgery and is unable to eat for a few weeks D. Client with anorexia nervosa E. Client who is having shoulder surgery

A. Client who has second- and third-degree (partial- or full-thickness) burns over 40% of the body C. Client who had gastric surgery and is unable to eat for a few weeks D. Client with anorexia nervosa A client with severe burns, as well as a client who has had gastric surgery, would both be a candidate for total parenteral nutrition. TPN is designed for clients who are severely malnourished who will not be able to eat for a long period. A client with anorexia nervosa would also be an appropriate candidate for TPN. A client who has peptic ulcer disease will be able to eat after initiation of a medication regimen. A client who is having shoulder surgery will likely be able to return to a normal diet within a short time frame.

Which of the following provides clues about fluid volume status? Select all that apply. A. Hourly urine output B. Daily weights C. Percentage of meals eaten D. Skin turgor E. Oxygen saturation

A. Hourly urine output B. Daily weights Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Percentage of meals eaten, skin turgor, and oxygen saturation would not be reliable indicators of fluid volume status in the burn injured patient.

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply. A. Hypotension B. Tachycardia C. Venous pooling D. Diaphoresis E. Tachypnea F. Hypothermia

A. Hypotension C. Venous pooling E. Tachypnea F. Hypothermia The vital organs are affected in a spinal cord injury, causing the blood pressure and heart rate to decrease. This loss of sympathetic innervation causes a variety of other clinical manifestations, including a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the patient does not perspire on the paralyzed portions of the body because sympathetic activity is blocked; therefore, close observation is required for early detection of an abrupt onset of fever.

A laboring woman with a history of a previous cesarean birth suddenly begins to exhibit manifestations of hypovolemic shock. Suspecting either complete or partial uterine rupture, which priority interventions should the nurse implement first? Select all that apply. A. Increase IV fluids immediately. B. Prepare to administer IV oxytocin to assist with uterine contraction. C. Call respiratory therapy to obtain ABGs. D. Prepare to administer epinephrine directing into the uterine muscle. E. Weigh all the blood-saturated bandages to determine amount of blood loss.

A. Increase IV fluids immediately. B. Prepare to administer IV oxytocin to assist with uterine contraction. Because the uterus at the end of pregnancy is such a vascular organ, uterine rupture is an immediate emergency. The nurse should administer emergency fluid replacement therapy as prescribed and anticipate the use of IV oxytocin to attempt to contract the uterus and minimize bleeding. ABGs are not the priority. Epinephrine is not given by direct injection into a muscle but by IV infusion during a code to cause vasoconstriction, thereby increasing BP. Blood lost will be estimated. Weighing saturated bandages is not the priority.

A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply. A. The client who is in the first 15 minutes of receiving 1 unit of PRBCs B. The 55 year-old client with spina bifida C. The client who is scheduled for a repeat CT scan of the abdomen D. The client with an infection who is prescribed intravenous vancomycin E. The client who reports an allergy to peanuts that causes throat swelling

A. The client who is in the first 15 minutes of receiving 1 unit of PRBCs B. The 55 year-old client with spina bifida E. The client who reports an allergy to peanuts that causes throat swelling Risk factors for anaphylactic shock include transfusion reaction, latex allergy, and severe allergy to foods or medications. The client in the first 15 minutes of receiving blood is at risk for an anaphylactic reaction. This is why the nurse should remain in the room for the first 15 minutes of infusion. The client with spina bifida is at risk for a latex allergy, which, in turn, increases the risk for an anaphylactic reaction if latex gloves are used. The client with a peanut allergy is at risk for an anaphylactic reaction if food is prepared or accidentally contaminated with a nut-based oil. The other clients are not at an increased risk for anaphylactic shock.

A nurse working in a community based clinic recently gave a presentation to parents of toddlers regarding care for injuries in the home. The child of one of the couples that attended the presentation pulled a cup of hot coffee off their kitchen table, causing superficial burns on the hands. Which initial actions by the parents demonstrate learning occurred from the presentation? Select all that apply. A. The parents ran cool water over the child's hands B. The parents applied ice to the burn to help with the pain C. The parents applied burn cream to the hands after cleansing D. The parents covered the burns with a clean non-adhesive bandage E. The parents contacted their physician for an appointment

A. The parents ran cool water over the child's hands D. The parents covered the burns with a clean non-adhesive bandage E. The parents contacted their physician for an appointment Suggested care for superficial burns includes running cool water over the burned area until the pain lessens, not applying ice, butter, ointment, or cream to the skin, covering the burn lightly with a clean, nonadhesive bandage, and administering acetaminophen or ibuprofen for pain. Have the child seen by the physician or nurse practitioner within 24 hours.

There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply. A. an 8-year-old with third-degree burns over 10% of the body surface area (BSA) B. a 20-year-old who inhaled the smoke of the fire C. a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA) D. a 30-year-old with second-degree burns on the back of the left leg (about 9% of body surface area (BSA) E. a 40-year-old with second-degree burns on the right arm (about 10% of BSA)

A. an 8-year-old with third-degree burns over 10% of the body surface area (BSA) B. a 20-year-old who inhaled the smoke of the fire C. a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA) Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.

A client is admitted to the hospital with a prerenal disorder, a nonurologic condition that disrupts renal blood flow to the nephrons, affecting their filtering ability. One cause of prerenal acute kidney injury is: A. anaphylaxis B. myoglobinuria C.secondary to burns D. polycystic disease E. ureteral stricture

A. anaphylaxis Anaphylaxis is a cause of prerenal acute renal failure. Myoglobinuria secondary to burns is a cause of intrarenal acute renal failure. Polycystic disease is a cause of intrarenal acute renal failure. Ureteral stricture is a cause of postrenal acute renal failure.

There has been a fire in an apartment building, and it has spread to seven apartment units. Victims have suffered burns, minor injuries, and broken bones from jumping from windows. Which persons can be safely treated at the scene and transported to a health care facility after victims with more emergent problems have been transported first? Select all that apply. A. female client who is 5 months pregnant with no apparent injuries B. male who is 50 years of age with no injuries, rapid respirations, and coughing C. child who is 10 years of age with an apparent simple fracture of the humerus D. female who is 20 years of age with first-degree burns on hands and forearms E. male who is 75 years of age with second-degree burns on both legs

A. female client who is 5 months pregnant with no apparent injuries C. child who is 10 years of age with an apparent simple fracture of the humerus D. female who is 20 years of age with first-degree burns on hands and forearms The pregnant woman is not in imminent danger or likely to have a precipitous birth. The child who is 10 years of age is not at risk of infection and can be treated in an outpatient facility. First-degree burns are considered less urgent. The male with respiratory distress and coughing is transported first as he is likely experiencing smoke inhalation. The 75-year-old male with second-degree burns should also be also transported to a burn center or emergency department.

A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client? A. Slow heart rate B. Kidney stones and blood clots C. Imbalance in electrolytes D. Elevated central venous pressure (CVP)

B. Kidney stones and blood clots Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated hematocrit levels and blood cell counts indicate hemoconcentration, which means a high ratio of blood components in relation to watery plasma. This increases the potential for blood clots and urinary stones. In hypovolemia, the heart rate tends to be high as the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte levels tend to remain normal because they are depleted in proportion to the water loss. CVP is usually below 4 cm H2O.

A client has an increased intracranial pressure (ICP) of 20 mm Hg. The nurse should: A. give the client a warming blanket. B. administer low-dose barbiturates. C. encourage the client to take deep breaths to hyperventilate. D. restrict fluids.

C. encourage the client to take deep breaths to hyperventilate. Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: A. planning for the client's rehabilitation and discharge. B. providing emotional support to the client and family. C. maintaining the client's fluid, electrolyte, and acid-base balance. D. preserving full range of motion in all affected joints.

C. maintaining the client's fluid, electrolyte, and acid-base balance. After maintaining respirations, the most important immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. Planning for the client's rehabilitation and discharge, providing emotional support, and preserving full range of motion in all affected joints are important aspects of care but don't take precedence over maintaining the client's fluid, electrolyte, and acid-base balance.

Which statement made by the parent of a toddler during a discussion on the management of accidental poisoning should be corrected immediately by the nurse? A. "There is a big risk that the poison could get into the lungs and cause aspiration pneumonia." B. "I need to keep the telephone number of the poison control center where it is easily accessed." C. "The American Academy of Pediatrics had changed the guidelines of treating poisonings since I was a child." D. "I keep a bottle of ipecac syrup locked up but where I can get to it if necessary."

D. "I keep a bottle of ipecac syrup locked up but where I can get to it if necessary." In the summer of 2003 the U.S. Food and Drug Administration released the results of efficacy and toxicity studies done with the emetic drug syrup of ipecac and ruled that the drug was not effective for its intended use and it's been recommends that parents be advised to dispose of any ipecac that they may have at home. The other options present accurate statements regarding the management of an accidental poisoning.

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated? A. Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting. B. Increase the IV flow rate to offset fluids lost through the therapy. C. Apply a topical antibiotic cream to burns to prevent infection. D. Administer pain medication 30 minutes before therapy to help manage pain.

D. Administer pain medication 30 minutes before therapy to help manage pain. Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for pain about 30 minutes before the treatment in anticipation of the increased pain the client will experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy session. However, electrolyte loss can occur from open wounds during immersion, so the sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45 minutes before hydrotherapy unless it is an individualized need for a given client. Topical antibiotics are applied after hydrotherapy.

A child with 20% second- and third-degree burns is admitted to the burn center. The child weighs 44 lbs (20 kg). The nurse has started an IV infusion of lactated Ringer solution and inserted an indwelling catheter. Which of the findings indicate that the child is going into shock? Select all that apply. A. Urinary output is 25 ml/hr. B. Specific gravity is within normal limits. C. Pain is 7 on a pain scale of 1 to 10. D. Heart rate is elevated. E. Blood pressure is dropping.

D. Heart rate is elevated. E. Blood pressure is dropping. The child is observed for shock that can occur following a severe burn. Shock is noted by the increasing heart rate and dropping blood pressure. This child has an adequate urine output (more than 1 ml/kg body weight) and the specific gravity is within normal range. Pain is expected and is not an indicator of shock.

Which of the following types of shock will a nurse observe in a client with extensive burns? A. Anaphylactic shock B. Neurogenic shock C. Septic shock D. Hypovolemic shock

D. Hypovolemic shock Clients with extensive burns may exhibit hypovolemic shock due to the loss of blood or plasma. Clients with extensive burns are unlikely to display the symptoms of anaphylactic, neurogenic, or septic shock.

During the acute phase of a burn, a nurse should assess: A. the client's lifestyle. B. alcohol use. C. tobacco use. D. circulatory status.

D. circulatory status. During the acute phase of a burn, the nurse should assess the client's circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client's lifestyle and alcohol and tobacco use may be obtained later when the client's condition has stabilized.