Med Surg - Chapter 26 - Care of Patients with Burns
Which statement provided by the student nurse indicates the need for further teaching about nursing interventions performed during the nonsurgical management of a patient with burns? 1 "Allow the patient to ambulate every 2 hours initially." 2 "Maintain the patient in a neutral body position with minimal flexion." 3 "Reinforce to the patient and family that wearing pressure garments reduces scarring." 4 "Urge the patient to perform active range-of-motion exercises three times a day to prevent immobility."
1 "Allow the patient to ambulate every 2 hours initially." Ambulation is started as soon as possible after the fluid shifts have resolved because it helps to maintain mobility, inhibits bone density loss, and strengthens muscles. Ambulation of the patient should be performed two or three times a day initially and progress in length each time. Maintaining the patient in a neutral body position with minimal flexion prevents contractures. Wearing pressure garments helps prevent contractures and tight hypertrophic scars. Contractures and hypertrophic scars can inhibit mobility. Performing range-of-motion exercises actively at least three times a day prevents immobility.
When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? 1 "Every bedroom should have a separate smoke detector." 2 "Every room in the house should have a smoke detector." 3 "If you have a smoke detector, you don't need a carbon monoxide detector." 4 "The kitchen and the bedrooms are the only rooms that need smoke detectors."
1 "Every bedroom should have a separate smoke detector." Teach all people to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home. Recommendations are that each bedroom has a separate smoke detector, there should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Carbon monoxide detectors are instrumental in picking up other types of carbon monoxide gas, such as from a defective heating unit.
Which statement made by a patient who experienced 45% total body surface area burns to the face, neck, chest, and arms indicates positive adjustment to the injury? 1 "I am planning on returning to work gradually so that I don't get too tired." 2 "I am working with my family so they can do all of the chores I used to do." 3 "I hope the home care nurse can change my dressings so that I do not have to look at my wounds." 4 "My wife and I have decided to go to movies instead of baseball games so that people can't see me."
1 "I am planning on returning to work gradually so that I don't get too tired." Reintegrating into the family situation, assuming the roles and responsibilities performed before the injury, and gradual reintegration back into the community and work are positive signs of beginning successful adjustment. Not looking at the wounds and not participating in family life are indicators of poor adjustment. Although it is good that the patient is venturing outside of the home, the fact that he wants to remain unseen is a less positive indicator of adjustment.
The registered nurse is teaching the student nurse about the functions of the skin. What statement made by the student nurse indicates a need for further teaching? 1 "Skin activates vitamin A when exposed to sunlight." 2 "Skin triggers a response if there is any sensation of pain." 3 "Skin helps in the maintenance of fluid and electrolyte balance." 4 "Skin acts as a protective barrier against injury and microbial invasion."
1 "Skin activates vitamin A when exposed to sunlight." When the skin is exposed to sunlight, Vitamin D is activated. When there is a sensation of pain, the skin triggers a response, which allows a person to react. Skin helps maintain fluid and electrolyte balance through evaporation. Skin acts as a protective barrier against injury and microbial invasions.
What precautionary measure must individuals take to prevent fires? 1 Chimneys must be cleaned once in a year. 2 Space heaters must be placed on a cotton cloth. 3 One smoke detector must be placed in the house. 4 While drinking alcohol, smoking must be done in an open area.
1 Chimneys must be cleaned once in a year Chimneys must be cleaned once a year to avoid creosote accumulation, which is a highly flammable material. Patients must be advised not to smoke while drinking alcohol, as alcohol can cause drowsiness and a lit cigarette could be dropped. Clothing, bedding, and other materials should be kept away from space heaters. Smoke detectors must be placed in each bedroom and in stairwells.
What type of burn injury may require the nurse to remove smoldering clothing and metal objects that are close to the patient's body? 1 Flame burns 2 Chemical burns 3 Electrical burns 4 Radiation burns
1 Flame burns Metal objects are good conductors of electricity. A flame burn is a contact burn. Therefore, any clothing or metal objects in contact with the body must be removed to prevent further injury. Chemical burns are caused when specific chemicals are used; these burns can be managed by using suitable neutralizing agents. Electrical burns are caused by an electrical current that obstructs respiration. Radiation burns are caused by exposure to certain radiations.
Which type of burn injuries includes an escharotomy as a part of the treatment plan? 1 Full-thickness wounds 2 Deep full-thickness wounds 3 Deep partial-thickness wounds 4 Superficial partial-thickness wounds
1 Full-thickness wounds In a patient that sustained full-thickness wound, hard, leathery dead tissue is present. This forms from the coagulated particles of the destroyed skin, which is called eschar. These particles stick to the lower tissue layer, affecting the healing of the injury. If severe edema is present under the eschar, it can result in decreased blood flow, making chest movement difficult for breathing. This can be solved by performing an escharotomy. This surgical procedure relieves pressure, allows for normal blood flow, and facilitates breathing. In deep full-thickness wounds, the damage extends beyond the skin to muscles and bones. Thus, grafting can be used as a part of treatment. In deep partial-thickness wounds, eschar is formed but it is soft and dry, which makes removal easy. In superficial partial-thickness wounds, there is no eschar.
The nurse is reviewing a medication record for an older adult patient recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the patient is receiving which medication? 1 Furosemide 2 Digoxin 3 Dopamine 4 Morphine sulfate
1 Furosemide Furosemide, a diuretic, generally is not given to improve urine output for burn patients. Diuretics decrease circulating volume and cardiac output by pulling fluid from the circulating blood to enhance diuresis. This reduces blood flow to other vital organs. Digoxin may be used to strengthen the force of myocardial contractions in older adult patients. Dopamine may be given to increase cardiac output in older adult patients. Morphine sulfate may be indicated for pain management.
Which wound assessment characteristics suggest a superficial partial thickness burn injury? 1 Painful 2 Absence of blisters 3 Black-brown coloration 4 Moderate to severe edema
1 Painful Characteristics of a superficial partial thickness burn injury include pink to red coloration, mild to moderate edema, pain, and blisters. A black-brown coloration is more suggestive of full thickness burn injury. Absence of blisters and moderate to severe edema may be present with deep partial thickness to full thickness burn injuries.
What is the priority management care provided by the nurse to a patient who is suffering from inhalation injury after a major burn accident? 1 Securing the airway 2 Dressing the wound carefully 3 Supporting circulation and organ perfusion 4 Keeping the patient comfortable with analgesics
1 Securing the airway The priority nursing management care to be provided to a patient after an inhalation injury involves securing the airway. During a reconstitution phase after an inhalation injury, caring for a patient involves assessing the respiratory system, which is most critical to prevent life-threatening complications. Careful wound dressing is done to prevent infections. Supporting circulation and organ perfusion is done through fluid replacement. Keeping the patient comfortable with analgesics helps in the management of pain and fever. These are all performed after securing the airway.
Which is the largest organ of the human body? 1 Skin 2 Liver 3 Brain 4 Lungs
1 Skin The skin is the largest organ in the human body. The skin of an average adult has a surface area of over 21 square feet, and weighs 10,886 grams, based on the size and weight of the individual. The liver is the second largest organ in the human body, having an average weight of 1,560 grams. The brain is the third largest organ. Its average weight in a normal human body is 1,263 grams. The lungs are the fourth largest organ in the human body, and their average weight is 1,090 grams.
What is the rationale behind obtaining the patient's preburn weight? Select all that apply. 1 To calculate the fluid rates 2 To calculate the nutritional needs 3 To administer optimal drug doses 4 To determine the degree of injury 5 To determine total body surface area
1 To calculate the fluid rates 2 To calculate the nutritional needs 3 To administer optimal drug doses The patient's preburn body weight is useful in calculating fluid rates, nutritional needs, and drug doses. The patient's preburn weight is not useful in assessing the degree of injury. Depth and circumferential extremity assessment helps in determining degree of injury. The patient's height is useful in determining the total body surface area.
When is grafting required in the treatment of burn injuries? 1 When there is absence of skin cells 2 When there is damage to the blood vessels 3 When there is exposure to the nerve endings 4 When the dead tissue sticks to the lower tissue layers
1 When there is absence of skin cells Grafting is usually required in deep full-thickness and full-thickness burn injuries. In these injuries, there is full destruction of the entire epidermis and dermis, leaving no skin cells to repopulate. Therefore, these wounds do not regrow and the area of injury is not closed by wound contraction. Damage to the blood vessels in superficial-thickness wounds leads to blister formation. Exposure of nerve endings for stimulation results in intensifying the pain. Sticking of the dead tissue to the lower tissue layers will lead to eschar formation.
The health care provider has ordered a blood transfusion for a female patient with serious electrical burns. What hematocrit level reflects the need for transfusion when symptoms of hypoxia are present? 1 25% 2 18% 3 40% 4 36%
2 18% Patients who have suffered severe burns due to electrical injury may have impaired kidney function due to an imbalance of fluids and electrolytes. This causes hemodilution and lowers the hematocrit value. Blood transfusion is required when the hematocrit value is less than 20% to 25% and the patient has manifestations of hypoxia. The hematocrit value for a normal adult is 40% in females and 45% in males, so a hematocrit value of 40% is considered normal. A value of 36% is not low enough to warrant blood transfusion.
What is the initial bolus dose of morphine through patient-controlled analgesia (PCA)? 1 1 to 5 mg of morphine 2 5 to 10 mg of morphine 3 10 to 15 mg of morphine 4 15 to 20 mg of morphine
2 5 to 10 mg of morphine PCA reduces pain. Important techniques for the best use of PCA include giving an initial bolus of 5 to 10 mg of morphine (or equivalent drug). A dose of 1 to 5 mg is a subtherapeutic dose. A dosage of 10 to 15 mg of morphine is needed when the dose must be increased after the initial bolus dose. The dosage of 15 to 20 mg would not be used as an initial bolus dose, because the patient's response to the drug must be monitored. The optimal dose should be given first, and then the dose may be increased, depending on the patient's response to the drug.
An older patient has suffered a 45% body surface area burn from a house fire. Which complication is the patient at greater risk of developing because of age-related changes? 1 Anxiety 2 Acute kidney injury 3 Gastric stress ulcers 4 Ineffective pain management
2 Acute kidney injury The older patient is at greater risk of developing shock and acute kidney injury after a burn injury because resuscitation efforts may be limited due to underlying cardiac dysfunction that occurs with aging. Ineffective pain management, anxiety, and gastric stress ulcers can occur in any patient with a burn injury.
Which anatomical structures are absent in a histological section of the epidermis? 1 Hair follicles 2 Blood vessels 3 Sweat glands 4 Sebaceous glands
2 Blood vessels The epidermis is the outermost layer of the skin, made up mostly of scalelike cells called squamous cells. The epidermis has no blood vessels, and nutrients must diffuse from the second layer of the skin. Hair follicles, sweat glands, and sebaceous glands are the dermal appendages that originate at the dermis and extend to the epidermis.
Which physiologic effect may indicate mild carbon monoxide poisoning? 1 Altered mental state 2 Decreased visual acuity 3 Decreased blood pressure 4 Cardiopulmonary instability
2 Decreased visual acuity The physiologic effects associated with mild carbon monoxide poisoning are decreased visual acuity, slight breathlessness, decreased cerebral function, and headache. The physiological effects associated with moderate carbon monoxide poisoning are decreased blood pressure, altered mental state, and vertigo. In severe carbon monoxide poisoning, cardiopulmonary instability can be seen.
A patient received a burn due to contact with hydrochloric acid. The burn is brown in color with severe edema and absence of blisters. Which category of burn does the patient have? 1 Superficial burn 2 Full-thickness burn 3 Deep full-thickness burn 4 Deep partial-thickness burn
2 Full-thickness burn Burns caused due to chemicals such as strong acids (hydrochloric acid) are categorized as full-thickness burns. They are brown in color with severe edema and no blister formation. Superficial burns are characterized as pink to red in color with mild edema and no blister formation. Deep full-thickness burns are red to white in color with moderate edema; blister formation is rarely seen. Deep partial-thickness burns are characterized by their black color, absence of edema, and no blister formation.
Which type of burn injuries includes a fasciotomy as part of the treatment plan? 1 Superficial wounds 2 Full-thickness wounds 3 Deep partial-thickness wounds 4 Superficial partial-thickness wounds
2 Full-thickness wounds In patients with full-thickness wounds, edema is severe. Edema formed under the eschar may decrease blood flow to the injured site. The blood flow to the injured site can be increased by making an incision in the fascia, known as a fasciotomy. Superficial wounds damage only the epidermis with only mild edema. Deep partial-thickness wounds extend their damage to deeper layers of dermis; in this situation, few healthy skin cells remain and are able to repopulate. Superficial partial-thickness wounds cause damage to the upper third of the dermis layer, leaving a good blood supply.
A patient with severe burn injuries develops cellular potassium loss. What would the patient have? 1 Hypovolemia 2 Hyperkalemia 3 Hyponatremia 4 Metabolic acidosis
2 Hyperkalemia Hyperkalemia may occur as a result of direct cell injury, which releases large amounts of cellular potassium in the blood. Hypovolemia, or low blood volume, is caused by fluid loss from the burn site. Hyponatremia refers to the loss of sodium due to fluid loss. Metabolic acidosis may be caused by the loss of bicarbonate in the urine.
The nurse finds that the patient with burns has developed a low-grade fever. Which patient condition could be the reason for developing a low-grade fever? 1 Fluid resuscitation 2 Hypermetabolic condition 3 Inflammatory compensation 4 Parasympathetic nervous system compensation
2 Hypermetabolic condition A patient with burns will have a hypermetabolic condition, which increases the core body temperature. Because the patient loses heat through the burned areas, the core body temperature will increase. This results in a low-grade fever. Fluid resuscitation involves replenishing the body with fluids in case of fluid imbalances; this practice does not cause a low-grade fever. Inflammatory compensation helps by triggering the healing process in the injured tissues; it may not cause low-grade fever. Sympathetic nervous system compensation may not lead to a low-grade fever, but it may cause changes in the gastrointestinal, cardiovascular, and respiratory systems.
A patient with full-thickness burns to the lower extremities has had emergent fasciotomies. What assessment parameter does the nurse monitor to evaluate the effectiveness of the fasciotomies? 1 Reduced edema 2 Improved distal pulses 3 Improved blood pressure 4 Reduced fluid resuscitation needs
2 Improved distal pulses When edema is severe under the eschar of a full-thickness wound, blood flow to the area is compromised. Incisions, escharotomies, or fasciotomies are performed to relieve the growing pressure under the eschar. After the escharotomy or fasciotomy is performed, the assessment of improved perfusion is achieved by evaluating pulses distal to the procedure. Edema may not be reduced immediately due to inflammation from the incision. Blood pressure may be slightly elevated secondary to discomfort following the procedure. A fasciotomy does not necessarily indicate that fluid resuscitation will no longer be required.
A patient with burns who was admitted to the hospital 3 days ago develops paralytic ileus. Which pathophysiological phenomenon may be the cause of the patient's condition? 1 Increased secretion of cortisol 2 Increased secretion of epinephrine 3 Increased secretion of aldosterone 4 Increased secretion of catecholamines
2 Increased secretion of epinephrine The sympathetic nervous system responds to stress by increasing the secretion of epinephrine. This inhibits the gastrointestinal motility and leads to a reduction in the blood flow to the gastrointestinal tract. Peristalsis may be reduced, which may lead to a paralytic ileus. Severe burn injury will lead to increased secretions of cortisol, aldosterone, and catecholamines. These hormones may increase the metabolism in the body, thus increasing the needs of oxygen and calories.
What is the preferred route of administration for an opioid drug if the patient with burns who is suffering from pain is in the resuscitation phase? 1 Oral 2 Intravenous 3 Intramuscular 4 Subcutaneous
2 Intravenous During the resuscitation phase, the intravenous route is preferred for administering opioids to prevent delayed absorption. The oral route would not be preferred because there would be altered drug absorption. When the drug is administered intramuscularly or subcutaneously, the drug could absorb rapidly if edema is present, resulting in lethal drug doses.
A patient sustains severe burn injuries from contact with a hot liquid. Which type of burn injury would the nurse anticipate? 1 Dry heat injury 2 Moist heat injury 3 Contact burn injury 4 Chemical burn injury
2 Moist heat injury Burn injuries caused by hot liquids or steam are called moist heat injuries. Burn injuries due to open flame are called dry heat injuries. Contact burn injuries occur due to contact with hot surfaces. Chemical burn injuries are caused by a chemical spill.
A newly admitted patient has deep partial-thickness burns. The nurse expects to see which clinical manifestations? 1 Painful reddened blisters 2 Painful red and white blisters 3 Painless black skin with eschar 4 Painless, brownish-yellow eschar
2 Painful red and white blisters A painful red and white wound bed characterizes deep partial-thickness burns; blisters are rare. Painless, brownish-yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.
Which type of burns result in a reduction in the activation of vitamin D when exposed to sunlight? 1 Full-thickness burns 2 Partial-thickness burns 3 Deep full-thickness burns 4 Superficial-thickness burns
2 Partial-thickness burns Vitamin D is formed by the action of sunlight on the cholesterol compounds present in the dermis. In partial-thickness burn injuries, there is a complete damage of the epidermis and varying depths of damage to the dermis, so there is a reduction in the activation of vitamin D. In full-thickness burn injuries, there is destruction of the entire epidermis and dermis, leaving no skin cells to repopulate. The activation of vitamin D by the skin is completely stopped, not just reduced. In deep full-thickness burn injuries, the damage extends beyond the skin, so there is no scope for activation of vitamin D through the skin. In superficial-thickness burn injuries, only the top layer of skin is damaged; the dermis is not damaged. There is not any reduction in the activation of vitamin D.
Which interventions take priority during the first 24 to 48 hours after a patient receives minor burn injuries? Select all that apply. 1 Covering the patient with a blanket 2 Providing emotional support to the patient 3 Maintaining the patient's body temperature 4 Administering tetanus toxoid for prophylaxis 5 Keeping the patient comfortable with analgesics
2 Providing emotional support to the patient 3 Maintaining the patient's body temperature 5 Keeping the patient comfortable with analgesics The resuscitation phase begins at the onset of injury and continues for 24 to 48 hours. This includes providing emotional support to the patient, maintaining optimal body temperature to prevent hypothermia, and keeping the patient comfortable by administering analgesics to reduce the pain. Covering the patient with a blanket is general emergency management. Patients with prior tetanus toxoid immunization require tetanus toxoid if more than 5 years have passed since the immunization. Administration of tetanus toxoid would be an emergency option for contaminated, severe burns and does not need to happen in the first 24 to 48 hours following the injury.
Which clinical manifestation is indicative of wound healing for a patient in the acute phase of burn injury? 1 Sloughing of grafts 2 Scar tissue formation 3 Increasing wound drainage 4 Pale, boggy, dry, or crusted granulation tissue
2 Scar tissue formation Indicators of wound healing include the presence of granulation, reepithelization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.
Which is considered a late complication of burn injuries? 1 Sepsis 2 Scarring 3 Protein loss 4 Fluid imbalance
2 Scarring Scarring is a part of the healing process; this involves the replacement of the normal tissue by fibrous tissue after the wound is healed. Scarring occurs as a late complication after the burn injury is healed. Sepsis is not a late complication of burn injury; it is caused by bacteria worsening the tissue destruction in a burn injury. Protein loss occurs because of fluid and electrolyte imbalance; it is an early complication. Fluid imbalance is not considered a late complication.
A patient who was rescued from an explosion is provided fluid resuscitation. Which factor should be assessed in the patient after providing fluid resuscitation? 1 Hemoglobin levels 2 Serum sodium levels 3 Serum calcium levels 4 Alanine aminotransferase
2 Serum sodium levels A patient who was rescued from an explosion has a high risk of losing kidney function. Protein and myoglobin released into the blood from muscle trauma (rhabdomyolysis) can accumulate in the kidneys, impede renal blood flow, and cause renal failure, so fluid resuscitation must be provided to maintain a 30 to 50 mL per hour urine output. To assess kidney function after providing fluid resuscitation, serum sodium and creatinine levels and urine specific gravity should be monitored hourly. Monitoring renal function is also important to avoid fluid overload. Hemoglobin, alanine aminotransferase, and serum calcium levels should also be monitored, but these are not indicators of kidney function which is this patient's priority concern.
Which physiological action of carbon-monoxide manifests as "cherry red" coloration of skin in a patient with carbon-monoxide poisoning? 1 Oxygen unloading 2 Vasodilating effect 3 Binding to hemoglobin 4 Transporting across the lung membrane
2 Vasodilating effect Carbon-monoxide poisoning is a leading cause of death from a fire. The vasodilating effect of the carbon-monoxide causes a "cherry red" coloration of the skin. Usually, hemoglobin gets desaturated in the tissue and returns to venous blood. In carbon-monoxide poisoning, hemoglobin has a high affinity for carbon-monoxide; it doesn't get desaturated in the tissue. Oxygen unloading, binding to hemoglobin in place of oxygen, and transporting of carbon-monoxide across the lung membrane would not manifest as "cherry red" coloration of skin.
Which statement made by the student nurse indicates a need for further teaching about the important factors of standard wound dressing and the number of gauze layers to be used? 1 "The number of gauze layers depends on the site of the injury." 2 "The number of gauze layers depends on the patient's mobility." 3 "The number of gauze layers depends on the cause of the injury." 4 "The number of gauze layers depends on the depth of the injury."
3 "The number of gauze layers depends on the cause of the injury." Standard dressing procedures used during burn injuries use multiple layers of gauze after applying the topical agents on the wound. The number of gauze layers does not depend on the cause of the injury; it is only important during management of wound care. The number of gauze layers to be used depends upon the site of the injury, as the skin thickness varies all over the body. The wound dressing and the gauze layers should not impair a patient's mobility. Therefore, it is an important factor during wound dressing. The wound dressing and the number of gauze layers also depend upon the depth of the injury to prevent further complications and to promote proper healing.
Which part of the skin varies in depth in the human body? 1 Dermis 2 Epidermis 3 Dermal appendages 4 Subcutaneous tissue
3 Dermal appendages The dermal appendages such as sweat glands, oil glands, and hair follicles vary in depth in different body areas. The dermis is the second most layer of the skin, which is thicker than the epidermis. It is made up of collagen, fibrous connective tissue, and elastic fibers. The epidermis is the outermost layer of the skin, which is thinner than the dermis and contains no blood vessels. Subcutaneous tissues do not vary in depth in the human body.
A patient is suspected of having deep muscle burn injuries. Which reason would the nurse identify as a cause of burn injury? 1 Dry heat 2 Chemical 3 Electrical 4 Moist heat
3 Electrical Deep muscle injuries may be present even if the superficial muscles appear normal or uninjured. Muscle injuries can occur in the case of electrical burns. Dry heat injuries can damage the superficial layer of the skin. Chemical injuries can damage the epithelial tissues. Moist heat injuries can damage the superficial layer and tissues.
Which type of injury is called a "grand masquerader" of burns? 1 Dry heat injury 2 Chemical injury 3 Electrical injury 4 Radiation injury
3 Electrical injury Electrical injuries are burns that occur when electrical current enters the body. These injuries are known as "grand masquerader" of burns, because the surface injuries may look small, but the associated internal injuries can be extensive. Open flame in house fires and explosions cause dry heat injuries; skin tissue is damaged in a dry heat injury. Chemical injuries mostly occur in a home setting or in industries. Injury occurs directly to the tissues by causing liquefaction of skin and its proteins. Radiation injuries occur when people are exposed to large doses of radiation, but this rarely causes extensive skin damage.
Which part of the skin helps in the healing process after a burn injury? 1 Epidermis 2 Sweat glands 3 Epithelial cells 4 Sebaceous glands
3 Epithelial cells Epithelial cells present in the dermis layer of the skin are responsible for regrowth of the skin after a burn injury. The epidermis is the outermost layer of the skin, consisting of dermal appendages such as sweat glands, sebaceous glands, and hair follicles, which extend into the epidermis layer. Sweat glands and sebaceous glands are the dermal appendages that are present in the dermis layer and extend to the outer layer of the skin.
Which alteration observed in a patient rescued from a fire indicates pulmonary injury? 1 Reporting dizziness 2 Coughing with sputum 3 Inability to swallow fluids 4 Exhaling through the mouth
3 Inability to swallow fluids The patient who has been rescued from a fire may have pulmonary injury due to inhalation of carbon monoxide. Pulmonary injury is characterized by difficulty in swallowing and a brassy cough. Exhaling through the mouth is not an indication of pulmonary injury. Even in deep breathing or in congestion, patients exhale through the mouth. The patient may have dizziness due to an imbalance in body fluids and electrolytes. Carbonaceous sputum indicates pulmonary injury or airway obstruction. Cough with sputum can be seen with infections or chronic obstructive pulmonary disorder; it does not indicate pulmonary injury.
A patient with burns has developed sepsis. Which sign or symptom in the patient indicates fungal infection? 1 Lethargy 2 Hypothermia 3 Occasional diarrhea 4 Severe disorientation
3 Occasional diarrhea Sepsis, often present due to open burn wounds, can be caused due to fungi, gram-positive bacteria, and gram-negative bacteria. Signs and symptoms of fungal infection are the presence of occasional diarrhea, mild disorientation, and fever. Severe disorientation and lethargy are symptoms of gram-positive bacterial infection. Hypothermia is a symptom of gram-negative bacterial infection.
A patient receives a prescription for collagenase for the treatment of burns. To decrease the risk of infection, the nurse expects what else to be included on the patient's plan of care? 1 A narcotic 2 A loop diuretic 3 Polysporin powder 4 Blood glucose monitoring
3 Polysporin powder Autolysis is the process of tissue disintegration using the patient's own cellular enzymes. In this process, collagenase is applied directly to the burn wound, which may increase the patient's risk of infection. Therefore, polysporin powder should be used with collagenase to prevent the risk of infection. Narcotic pain medications are prescribed to reduce pain, not decrease the risk for infection. Diuretics enhance dieresis and reduce blood supply to vital organs, causing severe hypovolemic shock. Blood glucose levels are measured during the resuscitation phase and do not decrease the patient's risk for infection.
When asking about the occupational history of a patient with burn injuries, the nurse learns that the patient works in a nuclear power plant. Which type of burn injury would the nurse anticipate? 1 Dry heat injury 2 Chemical injury 3 Radiation injury 4 Contact burn injury
3 Radiation injury Radiation exposure and injuries tend to happen in industrial areas where there is a risk for radiation, such as a nuclear power plant. Dry heat injuries may be caused by exposure to flames. Chemical injuries occur when chemicals are spilled on the skin. Contact burn injuries may be caused by coming into contact with hot objects.
Which type of burn shows desquamation 2 to 3 days after the injury? 1 Deep full-thickness wound 2 Deep partial-thickness wound 3 Superficial full-thickness wound 4 Superficial partial-thickness wound
3 Superficial full-thickness wound In superficial full-thickness wounds, desquamation occurs 2 to 3 days after the injury. The area heals rapidly in 3 to 6 days without a scar or other complications. In deep full-thickness wounds, the destruction of the entire epidermis and dermis occurs, leaving no skin cells to repopulate. Deep partial-thickness wounds extend deep into the skin dermis and fewer healthy cells remain. In superficial partial-thickness wounds, injury occurs to the upper third of the dermis, leaving a good blood supply. These wounds are pink, moist, and blanch when pressure is applied.
During discharge teaching, which patient response suggests further instruction is needed related to self-management of burn wounds and the healing process? 1 "I should eat foods high in protein." 2 "I should notify my provider if I am losing weight." 3 "I should wear long-sleeved shirts and go outside later in the day to protect myself from the sun." 4 "Once I'm discharged I can stop wearing the tight compressing garments over my dressings."
4 "Once I'm discharged I can stop wearing the tight compressing garments over my dressings." To maintain optimum function, patients need to continue to wear compression garments and splints until the burn wounds are fully healed. Failing to wear the garments and splints can result in contractures and large scars. Eating foods high in protein, wearing long-sleeved shirts, and notifying the provider of weight loss are correct actions in self-management of burn injury.
The nurse is caring for a patient who is on mechanical ventilation because of severe burns. Which medication is appropriate for this patient? 1 Digoxin 2 Ketamine 3 Mannitol 4 Atracurium
4 Atracurium Atracurium is a paralytic drug that blocks all respiratory activities in the patient and makes mechanical ventilation easier to implement. Digoxin is appropriate for a patient who has a cardiac condition. Ketamine is an anesthetic agent used for a patient who is anticipating surgery. Mannitol is a diuretic used to treat increased intracranial pressure.
What is formed as a result of small blood vessel damage with superficial partial-thickness burn injuries? 1 Pain 2 Eschar 3 Edema 4 Blisters
4 Blisters In superficial partial-thickness wounds, the upper third of the dermis is where small blood vessels are injured, which results in leakage of large amounts of plasma into the epidermis. This process leads to the lifting of the heat-destroyed epidermis, causing blisters. In superficial partial-thickness wounds the nerve endings are exposed; this is responsible for the increase in pain at the site of injury. Eschar formation is absent in superficial partial-thickness wounds. The inflammatory reaction in the skin leads to the mild to moderate edema at the site of superficial partial-thickness wounds.
Which type of burn injury can convert to a deeper injury due to tissue hypoxia? 1 Superficial wounds 2 Full-thickness wounds 3 Deep full-thickness wounds 4 Deep partial-thickness wounds
4 Deep partial-thickness wounds Deep partial-thickness wounds affect the deeper layers of dermis, with only a few healthy skin cells remaining in the dermis layer. Blood supply to the injured area can be decreased through infection, hypoxia, or ischemia, resulting in more damage of the tissue; this can convert deep partial-thickness wounds to full-thickness wounds. Superficial wounds cause minimal damage to the skin, affecting the epidermal layer of the skin. Full-thickness wounds cause destruction of the entire epidermis and dermis. Deep full-thickness wound damage extends even deeper exposing the muscles and bones.
Why do blisters not form in deep partial-thickness wounds? 1 Due to the leakage of large amounts of plasma 2 Due to the destruction of entire epidermis and dermis layers 3 Due to the thick dead tissue particles that stick to the tissue layers 4 Due to the thick dead tissue layer which sticks to the underlying dermis
4 Due to the thick dead tissue layer which sticks to the underlying dermis Blister formation is absent in deep partial-thickness wounds due to the dead tissue layer, which is thick, sticks to the underlying dermis, and does not readily lift off the surface. Leakage of large amounts of plasma by small blood vessels present in the lower layer of dermis results in blister formation. Destruction of the entire epidermal and dermal layers is observed only during full-thickness wounds. Hard, dry, and leathery eschar that forms from coagulated particles of destroyed skin sticks to the tissue layers, making wound healing difficult in full-thickness wounds.
What is the characteristic of a burn caused by brief contact with a hot plate? 1 Severe edema 2 Red-white in color 3 Soft and dry eschar 4 Heals in about 2 weeks
4 Heals in about 2 weeks Burns caused due to brief contact with hot objects like a hot plate are categorized as superficial partial thickness. The healing time for superficial partial thickness burns is about 2 weeks. They appear pink to red in color, rather than red to white, due to minor vasoconstriction. Mild to moderate edema is seen in superficial partial thickness burns. Eschar is not formed in superficial partial thickness burns; it is seen in deeper, more severe burns.
Which category of burn injury reflects deep partial-thickness burns affecting 20% of the total body surface area (TBSA)? 1 Major burn 2 Minor burn 3 Severe burn 4 Moderate burn
4 Moderate burn Deep partial-thickness burns affecting 15% to 25% TBSA are classified as moderate burns. Partial-thickness burns affecting more than 25% of TBSA are classified as major burns. Deep partial-thickness burns affecting less than 15% of TBSA are considered minor burns. Burns are categorized as three types: major, minor, and moderate. There is no "severe" burn category.
Which type of burn is often referred to as a scald burn? 1 Contact 2 Dry heat 3 Chemical 4 Moist heat
4 Moist heat Moist heat burns are also referred to as scald burns, which are caused by contact with hot liquids or steam. Contact burns occur when hot metal, tar, or grease contacts the skin, often leading to a full-thickness injury. Dry heat burns are caused by open flame in house fires and explosions. Chemical burns usually occur in the home setting or in an industrial accident. They also can be the result of an assault. Injury occurs when chemicals directly contact the skin or are ingested.
The nurse is caring for a patient who has a severe burn injury and is receiving fluid resuscitation. The nurse should assess which laboratory findings to determine the patient's response to the therapy? Select all that apply. 1 Liver enzyme levels 2 Red blood cell count 3 White blood cell count 4 Serum creatinine levels 5 Blood urea nitrogen levels
4 Serum creatinine levels 5 Blood urea nitrogen levels Fluid shifts and fluid loss occur in patients with severe burns. Fluid resuscitation is implemented to maintain fluid balance in the patient's body. Serum creatinine levels are measured to assess fluid balance in the body, whereas blood urea nitrogen levels give information about kidney function. Fluid resuscitation will not affect the liver enzyme levels, red blood cell count, or white blood cell count. Therefore, it is not necessary to monitor these laboratory values while evaluating the effects of fluid resuscitation.
Which type of burn injury has a moist, pink wound bed and blanches when gentle pressure is applied? 1 Full-thickness 2 Deep full-thickness 3 Deep partial-thickness 4 Superficial partial-thickness
4 Superficial partial-thickness Superficial partial-thickness wounds are caused when the dermis is injured, leaving a good blood supply. These wound beds are pink and moist and blanch when pressure is applied. Full-thickness wounds have a hard, dry, leathery eschar, which is formed from coagulated particles of the destroyed skin. With deep full-thickness wounds, the injured area is blackened and depressed and sensation is completely absent. The surface of deep partial-thickness wounds is red and dry, and there are white areas in deeper parts of the wound.
Which type of burn injury heals without scar formation? 1 Full-thickness wounds 2 Deep full-thickness wounds 3 Deep partial-thickness wounds 4 Superficial partial-thickness wounds
4 Superficial partial-thickness wounds Superficial partial-thickness wounds affect the upper third of the dermis, leaving a good blood supply. Under proper supervision, a superficial partial-thickness wound will heal within 10 to 21 days without scar formation. Full-thickness burns damage the entire epidermis and dermis, leaving no skin cells to repopulate. Thus the healing of the wound does not take place through wound contraction. The damage from deep full-thickness wounds extends beyond the skin into the muscle and bone. These wounds need early excision and grafting. Deep partial-thickness wounds heal in 2 to 6 weeks with scar formation.
What should the nurse infer about the depth of the injury by the evidence of blister formation on the wound? 1 Superficial wounds 2 Full-thickness wounds 3 Deep partial-thickness wounds 4 Superficial partial-thickness wounds
4 Superficial partial-thickness wounds Superficial partial-thickness wounds show blisters as characteristic features, and the entire epidermis and upper third of the dermis is affected. Only the epidermal layer of the skin is affected during superficial wounds. Full-thickness wounds show blackening of the skin, with entire epidermis and dermis destruction. Deep partial-thickness wounds affect the epidermis and lower layers of dermis, usually with an absence of blisters.
Which burn injury is characterized by desquamation? 1 Full-thickness wound 2 Partial-thickness wound 3 Deep full-thickness wound 4 Superficial-thickness wound
4 Superficial-thickness wound Desquamation, or peeling of dead skin, is usually seen in a superficial-thickness wound, 2 to 3 days after the burn. These wounds heal within 3 to 6 days and do not leave a scar behind. A full-thickness wound generally blanches (lightens) on applying pressure. Dry, leathery eschar formation is observed in a partial-thickness wound. In a deep full-thickness wound, the affected area is blackened and depressed.
Which statement is true regarding the layers of skin? 1 The dermis is thinner than the epidermis. 2 The epidermal layer nourishes the dermal layer of the skin. 3 The epidermis and subcutaneous tissue are separated by the basement membrane. 4 The dermis consists of appendages such as sweat glands and oil glands.
4 The dermis consists of appendages such as sweat glands and oil glands. The skin is the largest organ of the body, and it has two major layers, the epidermis and the dermis. The sweat glands, oil glands, and hair follicles are dermal appendages. The dermis is thicker than the epidermis and is made up of collagen, fibrous connective tissue, and elastin fibers. The epidermis has no blood vessels; therefore, nutrients must diffuse from the dermis. The subcutaneous tissue lies below the dermis and is separated from the dermis by the basement membrane.
Which factor differentiates full-thickness wounds from deep full-thickness wounds? 1 Intensity of pain 2 Eschar formation 3 Blisters formation 4 Severity of edema
Edema is the major difference between full-thickness wounds and deep full-thickness burn injuries. In patients with deep full-thickness burn injuries, edema is completely absent. The presence of severe edema in patients is an indication of full-thickness wounds. Pain is absent in deep full-thickness wounds, and it may be present or absent in full-thickness burn injuries. Eschar formation is present in both types of injuries, and these are hard and elastic. Blisters are absent in both types of burn injuries.