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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.
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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.
A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
- A. 4 to 6 hours a day for 6 months
- B. During waking hours for 2 to 3 months after the injury
- C. Continuously
- D. At night while sleeping for a year after the injury
Correct Answer: C
Rationale: Elastic pressure garments should be worn continuously (23 hours/day) to minimize scarring and contractures, typically for months until scars mature.
A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?
- A. Maintenance of bed rest to aid healing
- B. Choosing appropriate splints and functional devices
- C. Administration of beta adrenergic blockers
- D. Prevention of venous thromboembolism
Correct Answer: D
Rationale: Preventing venous thromboembolism is crucial in the acute phase due to immobility and hypercoagulability. Bed rest is avoided, splints are chosen by therapists, and beta blockers are not standard.
An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
- A. The length of time since the burn
- B. The location of burned skin surfaces
- C. The source of the burn
- D. The total body surface area (TBSA) affected by the burn
Correct Answer: D
Rationale: TBSA is the primary determinant of systemic response, as larger burns cause greater fluid loss, metabolic demand, and organ stress. Time, location, and source are secondary factors.
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care?
- A. Fluid status
- B. Risk of infection
- C. Nutritional status
- D. Psychosocial coping
Correct Answer: A
Rationale: Fluid resuscitation is the immediate priority post-cardiopulmonary stabilization to address massive fluid losses through damaged skin, preventing hypovolemic shock. Infection, nutrition, and coping are addressed later.