week 5 cc
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? Rule of nines Lund and Browder method Hand method Parkland formula method
Lund and Browder method
Following a severe sunburn that resulted in second-degree burns with multiple blisters, the skin team nurse notices that after several weeks of treatment, the skin appears to be regenerating. The nurse contributes this to which structure of the skin? Keratinocytes Basement membrane zone Merkel cells Langerhans cells
Merkel cells
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? Details of the incident. Breathing status and lung sounds. Extensiveness and depth of the burns. Blood pressure and heart rate
blood pressure and heart rate
A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns? deep tissue cooling continuing inflammatory process protein cell coagulation All options are correct.
deep tissue cooling
The nurse is assessing an 80-year-old client who has scald burns on both hands and forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first? Clean the wounds with warm water. Apply antibiotic cream. Refer the client to a burn center. Cover the burns with a sterile dressing.
refer the client to a burn center
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
A client has experienced first degree burns due to sun exposure and states, "The itchiness is so bad, but I don't want to scratch because it hurts." What should the nurse recommend? Select all that apply. A warm bath An oral antihistamine An occlusive cream An emollient lotion Sunscreen with SPF 30 or higher
An oral antihistamine An emollient lotion
The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. Vomiting Burns Diarrhea Dehydration Trauma
Burns Dehydration
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? yellow red green black
yellow
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? Airway assessment Depth of the burn/s Presence of edema Percentage of body burned Pulse strength
Airway assessment Presence of edema Pulse strength
When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? Deep partial thickness Superficial partial thickness Full thickness Superficial
Deep partial thickness
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: on the back of the body. on the front of the body. for a circular pattern. on the buttocks.
on the front of the body
A client who has severe thermal burns and is on mechanical ventilation becomes delusional and attempts to remove the tubes. The nurse gives the client propofol, a sedative. As a result, it's most important that the client receive a supplementation of zinc. sodium. potassium. magnesium.
zinc
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
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? Slow heart rate Kidney stones and blood clots Imbalance in electrolytes Elevated central venous pressure (CVP)
kidney stones and blood clots
The client comes to the emergency department with skin burns and tells the practitioner that they were caused by a diathermy treatment. The practitioner understands that the burns were caused by which type of radiation injury? Ultraviolet radiation Non-ionizing radiation Ionizing radiation Electrical currents
non-ionizing radiation