Nokea
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.
You may also like to solve these questions
An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn?
- A. Apply ice to the site of the burn for 5 to 10 minutes.
- B. Wrap the patients affected extremity in ice until help arrives.
- C. Apply an oil-based substance or butter to the burned area until help arrives.
- D. Wrap cool towels around the affected extremity intermittently.
Correct Answer: D
Rationale: Cool towels or water applied intermittently relieve pain and limit tissue damage without causing hypothermia, which ice can induce. Oil-based substances like butter trap heat, worsening the burn.
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 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.
An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patients body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?
- A. Administer IV fluids
- B. Administer broad-spectrum antibiotics
- C. Administer IV potassium chloride
- D. Administer packed red blood cells
Correct Answer: A
Rationale: IV fluid administration is critical to address massive fluid losses and prevent hypovolemic shock in the initial burn-shock period. Antibiotics, potassium, or PRBCs are not immediate priorities.
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
- A. Instruct the patient to keep the wound site in a dependent position.
- B. Administer PRN analgesia as ordered.
- C. Assess the patients peripheral pulses distal to the dressing.
- D. Assist with passive range of motion exercises to set the new dressing.
Correct Answer: C
Rationale: Checking peripheral pulses ensures dressings are not too tight, preventing circulatory compromise. Dependent positioning is avoided, analgesia is given before dressing changes, and ROM exercises are not typically post-dressing.