Nokea
A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client?
- A. Presence of soot around nasal passages
- B. Fracture of the fibula with displacement
- C. Elevation of blood pressure and heart rate
- D. Partial-thickness burns to hands and wrists
Correct Answer: A
Rationale: If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly. Elevation of heart rate without hypotension is not as significant. Fracture to any bone as well as care of burns should be managed once the airway, breathing, and circulation are assessed and managed.
You may also like to solve these questions
The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?
- A. The wound will take up to 3 weeks to heal.
- B. Pain management will be a challenge.
- C. Skin grafting will be necessary.
- D. Ligaments, tendons, muscles, and bone are not involved.
Correct Answer: C
Rationale: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.
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
Correct Answer: B
Rationale: 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.
A client with a burn injury is in acute stress. The nurse knows that which of the following complications is prone to develop in this client?
- A. Anemia
- B. Gastric ulcers
- C. Hyperthyroidism
- D. Cardiac arrest
Correct Answer: B
Rationale: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.
Skin grafts are necessary for what type of burn?
- A. Superficial
- B. Superficial partial thickness
- C. Full-thickness
- D. First degree
Correct Answer: C
Rationale: 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.
Skin substitutes are often used after the wound is debrided and cleaned. What is the purpose(s) for the use of a skin substitute? Select all that apply.
- A. Lessen potential for infection
- B. Maximizes fluid loss
- C. Promotes granulation of tissue
- D. Covers the unstractiveness of the wound
- E. Sows regeneration of tissue
- F. Diminishes pain
Correct Answer: A,F
Rationale: Skin substitutes provide a temporary covering of the burn area and lessen the potential for infection. The covering decreases pain associated with contact and exposure to the air. The covering decreases fluid loss through evaporation and discourages granulation tissue, which contains fibroblasts causing scars. The skin substitute promotes tissue generation and healing.