Nokea
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.
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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.
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.
Which is the primary reason for placing a client in a horizontal position while smothering flames that are present?
- A. To prevent collapse and further injuries
- B. To keep fire and smoke from airway
- C. To extinguish flames more quickly
- D. To promote blood flow to the brain and vital organs
Correct Answer: B
Rationale: The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. The stop, drop, and roll method is a quick and efficient means to extinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.
Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?
- A. Myoglobin in the urine
- B. Increase in antidiuretic hormone (ADH)
- C. Elevation of blood glucose levels
- D. Hypermatremia
Correct Answer: A
Rationale: Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema.
A client is brought to the emergency department with burns in irregular shapes scattered over multiple areas of the body. Which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn?
- A. Rule of nines
- B. Use client's palm size
- C. Parkland formula
- D. Lund and Broweder burns assessment
Correct Answer: B
Rationale: A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client's palm size to approximate the total body surface. The palm is approximately 1% of a person's TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Broweder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of times quantitates burns that involve entire sections of the body, not scattered burns.