Nokea
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.
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A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member?
- A. Hes on a calorie-restricted diet in order to divert energy to wound healing.
- B. His body has consumed his fat deposits for fuel because his calorie intake is lower than normal.
- C. He actually hasnt lost weight. Instead, theres been a change in the distribution of his body fat.
- D. He lost many fluids while he was being treated in the emergency phase of burn care.
Correct Answer: B
Rationale: Hypermetabolism in the acute phase causes significant weight loss as the body catabolizes fat reserves, despite increased nutritional support. Calorie restriction is not used, fluid loss is earlier, and fat distribution changes are not typical.
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.
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 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 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.