Nokea
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?
- A. Thats something that you and your doctor will likely talk about after your scars mature.
- B. That is something for you to talk to your doctor about because its not a nursing responsibility.
- C. I know this is really important to you, but you have to realize that no one can make you look like you used to.
- D. Unfortunately, its likely that you will have most of these scars for the rest of your life.
Correct Answer: A
Rationale: Reconstructive surgery is considered after scars mature, typically within 1-2 years, making this an appropriate, hopeful response. Other options dismiss the patient's concern or lack empathy.
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A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm?
- A. Superficial partial-thickness
- B. Deep partial-thickness
- C. Full partial-thickness
- D. Full-thickness
Correct Answer: D
Rationale: A full-thickness burn extends through the epidermis, dermis, and into underlying tissues like muscle or bone, appearing charred and painless due to nerve destruction. Superficial partial-thickness affects the epidermis, deep partial-thickness involves the deeper dermis, and full partial-thickness is not a recognized term.
A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment?
- A. Monitoring fluid and electrolyte imbalances
- B. Providing education to the patient and family
- C. Treating infection
- D. Promoting thermoregulation
Correct Answer: B
Rationale: Education for the patient and family is a priority in the rehabilitation phase to support self-care and adjustment. Fluid imbalances, infection, and thermoregulation are addressed in the acute phase.
A home care nurse is performing a visit to a patients home to perform wound care following the patients hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication?
- A. Psychosis
- B. Post-traumatic stress disorder
- C. Delirium
- D. Vascular dementia
Correct Answer: B
Rationale: Post-traumatic stress disorder is a common complication in burn survivors, with a high prevalence due to the traumatic nature of the injury. Psychosis, delirium, and dementia are not typical.
A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following?
- A. Assess the patient for signs of electrolyte imbalances.
- B. Administer fluids as ordered.
- C. Assess the risk for injury recurrence.
- D. Assess the patients psychosocial state.
Correct Answer: D
Rationale: Psychosocial assessment is critical during rehabilitation, as burn recovery poses psychological challenges like PTSD or depression. Electrolyte imbalances are rare in this phase, fluids are not typically administered, and burn recurrence is unlikely.
A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.
- A. Promote truthful communication.
- B. Avoid asking the patient to make decisions.
- C. Teach the patient coping strategies.
- D. Administer benzodiazepines as ordered.
- E. Provide positive reinforcement.
Correct Answer: A,C,E
Rationale: Promoting truthful communication, teaching coping strategies, and providing positive reinforcement foster effective coping by building trust and skills. Decision-making supports autonomy, and benzodiazepines address anxiety, not coping.