Shock & Burns

Which statement would the nurse include in patient teaching in the rehabilitation phase for a burn patient who is concerned about the appearance of their burn scars? "Use a water-based moisturizer to improve the appearance of the scars." "Spend a moderate amount of time in direct sunlight to help the scar color get closer to the color of your uninjured skin." "You can begin to use a pressure garment on the partially healed wounds to keep the scar flat." "Cosmetic camouflage can help the scars blend in with the rest of your skin tone."

"Cosmetic camouflage can help the scars blend in with the rest of your skin tone."

Which teaching would the nurse provide in the rehabilitation phase for a burn patient who wants to resume sexual activity with their partner? "Don't worry, the burn injury will not impact sexual activity." "A specialist can assist you with that topic." "Scar tissue may make touch feel unpleasant." "Scar tissue will have a permanent reduction of sensation."

"Scar tissue may make touch feel unpleasant."

Greater than which percentage of the total body surface area (TBSA) is the threshold at which partial-thickness burn injuries would be referred to a burn center? 30% 25% 20% 10%

10%

When caring for a patient with systemic inflammatory response syndrome (SIRS), the nurse would maintain a blood glucose level of mg/dL with a continuous insulin and glucose infusion. Enter your answer as a range, using a hyphen.

140-180

Which amount of fluid would the nurse recognize as recommended for the first 24 hours after a burn injury? 2 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned 1 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned 4 mL lactated Ringer's/kg/ percent total body surface area (%TBSA) burned 6 mL lactated Ringer's/kg/ percent total body surface area (%TBSA) burned

2 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned

Which rule is used to calculate initial fluid resuscitation for hypovolemic shock? 2:1 3:1 Massive infusion 1:3

3:1

Which type of shock is a patient at risk for developing after an acute myocardial infarction (MI) from severe coronary artery disease? Neurogenic Cardiogenic Anaphylactic Hypovolemic

Cardiogenic

Which type of burn would be referred to a burn center? Second-degree burns Burns on the chest Partial-thickness burns less than 10% TBSA Chemical burns

Chemical burns

During which stage of shock does ventilation-perfusion mismatch initially occur? Refractory Compensatory Initial Progressive

Compensatory

Which action would the nurse take when caring for a patient who is having a computer tomography (CT) scan with contrast media? Obtain weight. Provide sedation. Assess NPO status. Confirm allergies.

Confirm allergies.

Which intervention is related to decreased peripheral perfusion to tissue would the nurse be prepared to implement when caring for a patient in shock? Select all that apply. One, some, or all responses may be correct. Continuous use of a pressure-relieving mattress Keeping the room cool to help prevent diaphoresis and pyrexia Use of the Trendelenburg position when the patient shows pallor Turning the patient every hour according to a turning schedule Planning for bathing when the patient is most rested to decrease oxygen demand

Continuous use of a pressure-relieving mattress Turning the patient every hour according to a turning schedule Planning for bathing when the patient is most rested to decrease oxygen demand

Which action would the nurse take for a patient who has thermal burns on the face, including the cheeks and the area around the eyes? Apply pressure over the orbital areas. Cover the face with ointments and gauze. Wrap sterile gauze around the face. Apply ointment only without the use of gauze.

Cover the face with ointments and gauze.

Which assessment finding would the nurse anticipate for the patient in cardiogenic shock? Angioedema Bradycardia Bradypnea Crackles on auscultation

Crackles on auscultation

Which physiological change occurs during burn shock? A massive shift of fluids from the intravascular to the interstitial spaces A massive shift of fluids from the interstitial to the intravascular spaces A gradual increase of protein in the vascular space A gradual increase in colloidal osmotic pressure

A massive shift of fluids from the intravascular to the interstitial spaces

Which definition of systemic inflammatory response syndrome (SIRS) is accurate? The failure of 2 or more organs A period of homeostasis A systemic response to a variety of insults A microbial invasion

A systemic response to a variety of insults

Which assessment is the initial focus for the nurse when caring for a patient with sepsis? Advance directives ABCs Level of consciousness (LOC) History

ABCs

Which advantage is associated with the use of a cultured epidermal autograft (CEA)? Reduced risk of infection Reduced risk of contractures Ability for graft to take well even with thin epidermal skin Ability to produce skin from a patient with large body burns

Ability to produce skin from a patient with large body burns

Which process can cause a chemical burn? Select all that apply. One, some, or all responses may be correct. Absorption Inhalation Ingestion Evaporation Condensation

Absorption Inhalation Ingestion

Which action would the nurse take first when caring for a patient in shock who has developed a temperature of 102.0°F, is flushed, and is reporting feeling uncomfortable? Administer ibuprofen per orders. Provide the patient with a cooling blanket. Prepare to administer antibiotics. Remove blankets to promote shivering and heat loss.

Administer ibuprofen per orders

Which measure is the primary method to help prevent the development of tetanus in a burn patient who has not received any active tetanus immunization within the previous 12 years? Administer tetanus toxoid. Provide musculoskeletal relaxants. Provide 100% oxygen. Administer tetanus immunoglobulin.

Administer tetanus immunoglobulin.

Which type of shock can occur due to a hypersensitivity reaction? Septic Hypovolemic Anaphylactic Cardiogenic

Anaphylactic

Which step would the nurse take to help a patient with burns of 23% TBSA meet their nutritional needs? Check that the patient's weight loss does not exceed 20% of the pre-burn weight. Record the patient's caloric intake each week. Encourage the patient to eat high-protein, high-fat foods. Ask a caregiver to bring the patient's favorite foods from home.

Ask a caregiver to bring the patient's favorite foods from home.

Which action would the nurse perform for a patient who just sustained partial-thickness burns on the hands and chest caused by a fire? Select all that apply. One, some, or all responses may be correct. Assess for inhalation injury. Provide 100% humidified oxygen. Assess airway, breathing, and circulation. Avoid dry dressings on the wounds. Avoid mechanical ventilation for 24 hours.

Assess for inhalation injury. Provide 100% humidified oxygen. Assess airway, breathing, and circulation.

Which facility would treat a patient who will need special social, emotional, or rehabilitative intervention after a severe thermal injury? Outpatient clinic Burn center Urgent care facility Psychiatric clinic

Burn center

Which information would the nurse use to monitor cerebral blood flow when assessing a patient in shock? Select all that apply. One, some, or all responses may be correct. Mild agitation Restlessness Elevated temperature Level of consciousness (LOC) Electrocardiogram (ECG) monitoring

Mild agitation Restlessness Level of consciousness

Which assessment is necessary to monitor for shock in a patient who is hemorrhaging? Select all that apply. One, some, or all responses may be correct. Monitor intake and output. Weigh the patient every 48 hours. Question the patient about known allergies. Use aseptic technique when assessing the patient. Compare all assessment findings to the previous findings.

Monitor intake and output Compare all assessment findings to the previous findings

Which action would be included in the care plan for a patient in shock? Select all that apply. One, some, or all responses may be correct. Monitor intake, output, and daily weight. Reduce noise and light in the patient's room. Brush the patient's teeth and gums every 2 hours. Adhere strictly to handwashing and minimize invasive procedures. Closely monitor blood pressure and use Trendelenburg position when it is low.

Monitor intake, output, and daily weight Reduce noise and light in patients room Adhere strictly to handwashing and minimize invasive procedures

Which type of shock can occur after a spinal cord injury? Septic Relative hypovolemia Neurogenic Cardiogenic

Neurogenic

Which type of shock would the nurse monitor for in a patient who had an epidural for a minor surgical procedure and now has developed a high fever, hypotension, and tachycardia? Septic Obstructive Neurogenic Cardiogenic

Neurogenic

Which description explains how healing occurs in the rehabilitation phase? New skin appears red and raised. Over several weeks, the healed area becomes sunken. New tissue shortens without adequate range of motion. Over several months, the healed area becomes dark in color.

New tissue shortens without adequate range of motion.

Which neurologic manifestation occurs during the refractory stage of shock? Select all that apply. One, some, or all responses may be correct. Nonreactive and dilated pupils Anxiety Acute kidney injury Ischemic gut Areflexia

Nonreactive and dilated pupils Areflexia

Which type of IV fluid infusion would the nurse anticipate administering to the patient with signs and symptoms of shock from an unknown etiology? Colloid solution Hypertonic solution Normal saline solution Packed red blood cells (RBCs)

Normal saline solution

Which order would the nurse expect to assess early signs of a systemic infection when caring for a patient with an indwelling urinary catheter? Select all that apply. One, some, or all responses may be correct. Delaying of antibiotic order until results of blood culture are obtained Obtaining a urine culture Drawing a blood culture Initiating renal dialysis Administering a broad-spectrum antibiotic

Obtaining a urine culture Drawing a blood culture Administering a broad-spectrum antibiotic

Which intervention would the nurse use to avoid low sodium levels in a burn patient? Ask the patient to drink water Offer the patient juice Administer insulin Provide a low-protein meal

Offer the patient juice

Which strategy would the nurse use when caring for a patient with burn injuries on the ears? Change the pillowcase frequently. Place a rolled-up towel under the shoulders. Use the dressing to apply light pressure to the ears. Use a special pillow that follows the contours of the head.

Place a rolled-up towel under the shoulders.

Which complication would the nurse anticipate in the acute phase of burn care for an 83-year-old patient with partial-thickness chemical burns? Select all that apply. One, some, or all responses may be correct. Pneumonia AKI Delirium Slow wound healing Slow healing of donor sites Hyperkalemia

Pneumonia Delirium Slow wound healing Slow healing of donor sites

Which action would the nurse take first when admitting a patient with multiple organ dysfunction syndrome (MODS) who is in acute respiratory distress syndrome (ARDS)? Collect laboratory values. Prepare for mechanical ventilation. Ensure a comfortable environment. Prepare for dialysis.

Prepare for mechanical ventilation.

During which stage of shock would the nurse anticipate the patient to be moved to the intensive care unit (ICU)? Refractory Initial Compensatory Progressive

Progressive

Which intervention would the nurse provide when caring for a patient with a burn injury during the acute phase? Provide teaching about the physical aspects of recovery. Discuss the possible need for home care nursing. Discuss the need for reconstructive surgery. Begin IV fluid replacement.

Provide teaching about the physical aspects of recovery.

Which strategy would the nurse use when caring for burn wounds during the emergent phase? Using a cloth to remove loose burn tissue Maintaining a room temperature of 76° F Re-estimating the total burn percentage during cleansing Providing emotional support to the patient

Providing emotional support to the patient

Which therapy would be used in the initial resuscitation of shock? Administration of antibiotics Delivery of packed red blood cells Providing normal saline Delivering plasma

Providing normal saline

Which instruction would the nurse include in the discharge teaching for a patient who received a cultured epithelial autograft (CEA) to the entire left leg? Refer the patient to a counselor for psychosocial support. Sit or lie in a position of comfort. Wear a pressure garment for eight hours each day. Use the sun to increase the skin color on the healed areas.

Refer the patient to a counselor for psychosocial support.

Which organ system would the nurse expect to be among those affected first in a patient admitted with septic shock and multiple organ dysfunction syndrome (MODS)? Select all that apply. One, some, or all responses may be correct. Renal Endocrine Respiratory Integumentary Cardiovascular

Renal Respiratory Cardiovascular

Which laboratory finding would the nurse expect when caring for a patient with early signs of shock? Select all that apply. One, some, or all responses may be correct. Metabolic acidosis Respiratory alkalosis Elevated sodium level Decreased potassium level Elevated liver enzyme levels

Respiratory alkalosis Elevated sodium level Decreased potassium level

Which priority goal would the nurse set for a patient in shock? Select all that apply. One, some, or all responses may be correct. Restoration of baseline BP Understands prevention efforts Adequate tissue perfusion Avoid complications of hypoperfusion Recovery of organ function

Restoration of baseline BP Adequate tissue perfusion Avoid complications of hypoperfusion Recovery of organ function

Which physiologic change marks the end of the emergent phase of burn management? Decrease in sodium levels Increase in potassium levels Return of fluid to the interstitial space Restoration of capillary membrane permeability

Restoration of capillary membrane permeability

Match type of burn to the anticipated assessment finding. Fluid-filled vesicles that are red, shiny, and wet Insensitivity to pain Erythema, blanching on pressure, and pain

Second Third First

Which concern would the nurse have when a patient in the intensive care unit (ICU) exhibits hypotension, tachycardia, tachypnea, hyperthermia, confusion, and drowsiness? Septic shock Heightened anxiety Has hemorrhagic shock Acute multiple organ dysfunction syndrome (MODS)

Septic shock

Which information obtained by the nurse would suggest that a patient with cardiogenic shock is developing multiple organ dysfunction syndrome (MODS)? Patient reports intermittent chest pressure. Wheezes are heard throughout both lung fields. Extremities are cool and pulses are weak. Serum creatinine level is elevated.

Serum creatinine level is elevated

Which statement describes why a patient receiving treatment for shock would have an elevated white blood cell (WBC) count and procalcitonin (PCT) level? Shock is starting to reverse. Patient is bleeding and needs more fluids to treat shock. Shock is caused by a systemic bacterial infection. Patient has developed acute disseminated intravascular coagulation (DIC).

Shock is caused by a systemic bacterial infection

Which item is a common household source of burn injury? Fertilizers Chemicals Combustible fuels Space heaters

Space heaters

Which action would the nurse take within the first hour of diagnosis of sepsis? Select all that apply. One, some, or all responses may be correct. Administer vasopressin. Administer insulin. Start antibiotics. Collect blood cultures. Start venous thromboembolism (VTE) prophylaxis.

Start antibiotics. Collect blood cultures.

Which priority action would the nurse take when the patient exhibits difficulty breathing, wheezing, chest pain, and anxiety after starting an IV antibiotic? Administer oxygen. Stop the IV infusion. Administer epinephrine. Notify the health care provider.

Stop the IV infusion

Which complication would the nurse suspect in a burn patient with decreased blood pressure, increased heart rate, chills, and decreased urine output? Systemic infection Acute kidney injury Curling ulcer Hypernatremia

Systemic infection

Which assessment finding would the nurse expect to see in a patient experiencing progressive shock? Decrease in alertness Hypertension Bradycardia Increased urine output

Decrease in alertness

Which advantage is associated with the use of newer types of dressings on donor sites? Decreased healing time Decreased infection Decreased cost Decreased moisture

Decreased healing time

For which reason would the nurse strive to provide optimal nutrition support when caring for a patient with systemic inflammatory response syndrome (SIRS)? Provides glycemic control Prevents weight loss Decreases morbidity Promotes comfort

Decreases morbidity

Which factor is used to determine the severity of burn injuries? pH of the chemical agent Depth of the burn Severity of pain Age of the patient

Depth of the burn

Which description characterizes a full-thickness burn? Viable skin elements Dry, waxy white, or hard skin Severe pain Pain and mild swelling

Dry, waxy white, or hard skin

Which factor impacts the severity of an injury caused by a thermal burn? Duration of skin contact Source of the burn pH of the agent Force exerted

Duration of skin contact

Which type of burn can cause cervical spinal injury? Thermal Radiation Chemical Electrical

Electrical

Which type of burn would put the patient at risk for acute kidney injury? Chemical Thermal Electrical Radiation

Electrical

Which action can help a burn patient address their emotions and psychological distress? Avoiding other burn patients Relying on caregivers Downplaying their emotions Emphasizing what they are capable of doing

Emphasizing what they are capable of doing

Which step would the nurse take in the acute phase to help a patient with arm burns regain and maintain muscle strength and optimal joint function? Select all that apply. One, some, or all responses may be correct. Discourage the patient from moving during dressing changes. Ensure the patient is medicated during dressing changes. Remove bulky dressings to allow for exercise. Check the skin for signs of excessive pressure from splints. Adjust the patient's schedule frequently when wearing splints.

Ensure the patient is medicated during dressing changes. Remove bulky dressings to allow for exercise. Check the skin for signs of excessive pressure from splints.

Which intervention would the nurse anticipate when caring for a patient with systemic inflammatory response syndrome (SIRS) that is progressing to multiple organ dysfunction syndrome (MODS)? Select all that apply. One, some, or all responses may be correct. Enteral feedings Infusion of glucose and insulin Administration of loop diuretics Progressive mobilization to aerate lungs Continuous electrocardiogram (ECG) monitoring

Enteral feedings Infusion of glucose and insulin Administration of loop diuretics Continuous electrocardiogram (ECG) monitoring

Which nursing action is necessary for successful management of shock? Select all that apply. One, some, or all responses may be correct. Establish IV access Fluid resuscitation with crystalloids Initiate oral hydration Optimize oxygen delivery Early recognition

Establish IV access Fluid resuscitation with crystalloids Optimize oxygen delivery Early recognition

At which interval would the nurse assess the neurologic status of a patient in shock? Every 5 to 10 minutes Every 1 to 2 hours Every 4 hours Continuously

Every 1 to 2 hours

Which condition would put a patient at risk for hypovolemic shock? Select all that apply. One, some, or all responses may be correct. Spinal cord injury Excessive hemorrhaging Myocardial infarction Urinary tract infection Prolonged vomiting and diarrhea

Excessive hemorrhaging Prolonged vomiting and diarrhea

Which facet of patient care can be challenging for the nurse? Limited interaction with patients Lack of emotional connection with patients Short-term responsibilities when caring for patients Exposure to sights and smells of burn injuries

Exposure to sights and smells of burn injuries

Which factor would put a burn patient at increased risk for venous thromboembolism (VTE)? Select all that apply. One, some, or all responses may be correct. Malnourishment Lack of sleep Extensive burns Prolonged immobility Upper extremity burns

Extensive burns Prolonged immobility

Which step would the nurse take to prevent curling ulcer in the acute phase of burn care? Feed the patient quickly after the burn injury. Tell the patient to avoid drinking too much water. Keep the room warm. Check the patient's glucose levels frequently.

Feed the patient quickly after the burn injury.

Which area is especially susceptible to contractures in the rehabilitation phase? Select all that apply. One, some, or all responses may be correct. Fingers Anterior and lateral neck areas Abdomen Groin areas Knees Thighs

Fingers Anterior and lateral neck areas Groin areas Knees

Which strategy would the nurse implement to decrease the risk for health care-associated infections (HAIs)? Monitor intake and output. Monitor laboratory values. Start prophylactic antibiotics. Follow infection control practices.

Follow infection control practices.

Which type of burn may injure fat? First-degree burn Second-degree burn Partial-thickness burn Fourth-degree burn

Fourth-degree burn

Which type of burn may impair perfusion distal to the injury? Full-thickness circumferential extremity burns Joint burns Burns on the buttocks Neck burns

Full-thickness circumferential extremity burns

Which change occurs in the acute phase of burn care? Select all that apply. One, some, or all responses may be correct. Pain decreases. Healing begins. Necrotic tissue sloughs. Patient gains hope. Vital signs stabilize. Complications occur with major burns.

Healing begins. Necrotic tissue sloughs. Vital signs stabilize. Complications occur with major burns.

Which source is a cause of burns? Select all that apply. One, some, or all responses may be correct. Heat Chemicals Electric current Radiation Air Metal

Heat Chemicals Electric current Radiation

Which dietary choice would the nurse implement for a patient with partial- and full-thickness burns on 65% of their body? Full liquids only Any food requested by the patient High protein foods Low carbohydrate foods

High protein foods

Which abnormal finding would the nurse anticipate from the laboratory results of a patient in a late stage of shock? Select all that apply. One, some, or all responses may be correct. Hyperkalemia Hyperglycemia Metabolic acidosis Elevated lactate acid level Elevated liver enzyme levels

Hyperkalemia Metabolic acidosis Elevated lactate acid level Elevated liver enzyme levels

Which finding is consistent with the compensatory stage of shock? Select all that apply. One, some, or all responses may be correct. Hypoactive bowel sounds Temperature of 98.6°F Cool and clammy skin Crackles on auscultation Anuria

Hypoactive bowel sounds Temperature of 98.6F Crackles on auscultation Anuria

Match each type of shock with its cause. Loss of intravascular fluid Systolic or diastolic dysfunction Massive vasodilation without compensation Acute allergic reaction to a sensitizing substance

Hypovolemic Cardiogenic Neurogenic Anaphylactic

Which event explains why a burn patient would have hypokalemia in the acute phase of burn care? IV therapy did not include potassium supplementation. Damaged cells released large amounts of potassium. The patient received large amounts of hypertonic solutions. The patient drank too much water.

IV therapy did not include potassium supplementation.

Which physiologic change impacts the patient's nutritional needs after a major burn injury? Decrease in core temperature Massive anabolism Increase in resting metabolic expenditure Delayed healing

Increase in resting metabolic expenditure

When monitoring disseminated intravascular coagulation (DIC) screening labs, which result would the nurse anticipate in a patient in shock? Increased thrombin time Normal D-dimer Decreased prothrombin time (PT) Increased platelet count

Increased thrombin time

Which statement describes how burn patients may experience delirium? It is usually permanent. It is more common in younger adults. It is more acute at night. It typically begins in the emergent phase.

It is more acute at night.

Which assessment finding is an early indicator of systemic inflammatory response syndrome (SIRS) or multiple organ dysfunction syndrome (MODS)? Lethargy Skin mottling Acute respiratory distress syndrome (ARDS) Hypoglycemia

Lethargy

Which factor contributes to older adults' challenges during burn care? Select all that apply. One, some, or all responses may be correct. Thicker dermal layers Loss of elastic fibers Longer healing time Longer rehabilitation time Increased vascularity

Loss of elastic fibers Longer healing time Longer rehabilitation time

Which assessment finding would the nurse expect if a patient who presents with a broken femur is developing shock? Select all that apply. One, some, or all responses may be correct. Dry skin Increased urinary output Low blood pressure Decreased pulse Prolonged capillary refill

Low blood pressure Prolonged capillary refill

Which step would the nurse take when feeling overwhelmed from caring for a newly married patient with full-thickness burns during the past 10 months? Select all that apply. One, some, or all responses may be correct. Talk to their manager about the situation. Use counseling services offered through the facility's employee assistance program. Spend more time relaxing at home. Talk to the patient directly about their feelings. Use a peer support group.

Talk to their manager about the situation. Use counseling services offered through the facility's employee assistance program. Spend more time relaxing at home. Use a peer support group.

Which step would the nurse take to prevent burn accidents? Teach community members about burn prevention strategies Write burn safety education curriculum for schools Advocate for stricter building codes Distribute anti-scald devices

Teach community members about burn prevention strategies

Which description explains how Integra artificial skin is used? The Integra artificial skin has two layers, one of which eliminates the need for an epidermal autograft. The Integra artificial skin is a standard substitute for a conventional autograft for any type of burn wound. The Integra artificial skin system includes a permanent dermal layer and a cosmetic layer to even skin tone. The Integra artificial skin system requires two surgeries for excision, application, and epidermal autograft.

The Integra artificial skin system requires two surgeries for excision, application, and epidermal autograft.

Which type of burn injury is the most common? Thermal Chemical Electrical Cold thermal

Thermal

Which intervention would the nurse prioritize when caring for a patient with a suspected spinal injury and neurogenic shock? Ambulate. Utilize cooling devices. Initiate massive fluid resuscitation. Treat hypotension.

Treat hypotension.

Which intervention would be performed to prevent skin breakdown in the patient in shock? Select all that apply. One, some, or all responses may be correct. Turn and reposition Range of motion Brush teeth Pressure-reducing mattress Administer medication

Turn and reposition Range of motion Pressure-reducing mattress

Which finding indicates a progression to severe renal dysfunction in a patient with shock that has progressed to systemic inflammatory response syndrome (SIRS)? Select all that apply. One, some, or all responses may be correct. Urine output of 2.5 L/day Urine specific gravity of 1.032 Urine sodium level of 18 mEq/L Urine osmolality of 980 mOsm/kg Blood urea nitrogen (BUN) level of 5 mg/dL and creatinine level of 0.3 mg/dL

Urine specific gravity of 1.032 Urine sodium level of 18mEq/L Urine osmolality of 980 mOsm/kg

Which action can reduce burn injury in homes? Hold onto a child while cooking. Set the water heater thermostat to 130°F or lower. Test smoke alarms once per year. Use a flame-retardant smoking apron.

Use a flame-retardant smoking apron.

Which item can cause a chemical burn? Select all that apply. One, some, or all responses may be correct. Wet cement Lye Phenols Petroleum products Paint Scalding liquids

Wet cement Lye Phenols Petroleum products

Which emotional response is the most common among burn patients? Wide range of emotions Hopelessness Frustration Optimism and hope

Wide range of emotions