Nokea
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.
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The nurse caring for a patient who is recovering from full-thickness burns is aware of the patients risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk?
- A. Apply skin emollients as ordered after granulation has occurred.
- B. Keep injured areas immobilized whenever possible to promote healing.
- C. Administer oral or IV corticosteroids as ordered.
- D. Encourage physical activity and range of motion exercises.
Correct Answer: D
Rationale: Physical activity and range of motion exercises prevent contractures and hypertrophic scarring by maintaining joint mobility and reducing tissue shortening. Emollients and immobilization are not standard, and corticosteroids slow healing.
A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock?
- A. Confusion
- B. High fever
- C. Decreased blood pressure
- D. Sudden agitation
Correct Answer: C
Rationale: Decreased blood pressure signals burn shock onset due to reduced vascular volume from fluid loss. Confusion, fever, or agitation are not primary indicators.
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?
- A. Sodium deficit
- B. Decreased prothrombin time (PT)
- C. Potassium deficit
- D. Decreased hematocrit
Correct Answer: A
Rationale: Sodium deficit (hyponatremia) occurs in the emergent phase due to sodium loss in edema fluid. Potassium is elevated, hematocrit increases, and PT is not typically decreased.
A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
- A. Early enteral feeding
- B. Administration of prophylactic antibiotics
- C. Bowel cleansing procedures
- D. Administration of stool softeners
Correct Answer: A
Rationale: Early enteral feeding supports the intestinal mucosal barrier, reducing permeability and preventing endotoxin translocation. Prophylactic antibiotics risk resistant bacteria, and bowel cleansing or stool softeners do not address this issue.
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.