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A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm?
- A. Superficial partial-thickness
- B. Deep partial-thickness
- C. Full partial-thickness
- D. Full-thickness
Correct Answer: D
Rationale: A full-thickness burn extends through the epidermis, dermis, and into underlying tissues like muscle or bone, appearing charred and painless due to nerve destruction. Superficial partial-thickness affects the epidermis, deep partial-thickness involves the deeper dermis, and full partial-thickness is not a recognized term.
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A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what?
- A. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
- B. Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis
- C. Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis
- D. Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
Correct Answer: A
Rationale: In the emergent phase, cell damage releases potassium (hyperkalemia), sodium is lost to edema (hyponatremia), hemoconcentration increases hematocrit, and tissue hypoxia causes metabolic acidosis. Other combinations do not align with burn pathophysiology.
A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation?
- A. Pain
- B. Fluid balance
- C. Anxiety and fear
- D. Airway management
Correct Answer: D
Rationale: Airway management is the priority due to the risk of obstruction from smoke inhalation-induced edema, following the ABCs of trauma care. Pain, fluid balance, and anxiety are secondary.
A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury?
- A. 2 days
- B. 3 days
- C. 5 days
- D. 1 week
Correct Answer: A
Rationale: Upper airway edema from burns can develop up to 48 hours post-injury due to inflammation and fluid shifts, requiring vigilant monitoring. Later onset is less likely.
A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patients needs?
- A. A patient-controlled analgesia (PCA) system
- B. Oral opioids supplemented by NSAIDs
- C. Distraction and relaxation techniques supplemented by NSAIDs
- D. A combination of benzodiazepines and topical anesthetics
Correct Answer: A
Rationale: PCA allows the patient to control parenteral opioid delivery, providing consistent relief for severe burn pain. Oral medications, distraction, or benzodiazepines alone are insufficient for acute burn pain.
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.