Nokea
A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?
- A. Rule of nines
- B. Lund and Browder method
- C. Hand method
- D. Parkland formula method
Correct Answer: B
Rationale: The Lund and Browder method divides the body into smaller segments. Different percentages are assigned to body parts, depending on patient's age. For example, the adult head is equivalent to 9%, whereas the infant head is 19%. This method is more accurate when dealing with children. The rule of nines and hand method are quick assessment techniques for estimating burns. The Parkland formula incorporates fluid resuscitation requirements for burns.
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Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?
- A. Myoglobin in the urine
- B. Increase in antidiuretic hormone (ADH)
- C. Elevation of blood glucose levels
- D. Hypermatremia
Correct Answer: A
Rationale: Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema.
During the recovery of an extensive burn, the client is complaining about wearing the tight-fitting custom garment. What is an appropriate response by the nurse?
- A. Perhaps the garment should be resized.
- B. The garment acts as a skin layer and prevents infection.
- C. A snug fit is needed to minimize scarring and to smooth the skin.
- D. The garment can be removed for an hour each day.
Correct Answer: C
Rationale: The forming of burn scars can be minimized by the use of pressure dressings and custom-fitted garments that apply continuous pressure. Garments need to be snug in order to be effective. These garments are worn for 23 hours a day and may be prescribed for as long as 2 years. Prevention of infection is not indicated with use.
Which type of debridement occurs when nonliving tissue slough away from uninjured tissues?
- A. Mechanical
- B. Natural
- C. Enzymatic
- D. Surgical
Correct Answer: B
Rationale: Natural debridement is accomplished when nonliving tissue slough away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.
What skin substitute is a nylon-silcone membrane coated with a protein derived from pig tissue?
- A. Mederma
- B. Integra
- C. TransCyte
- D. Biobrane
Correct Answer: D
Rationale: Biobrane is a nylon-silcone membrane coated with a protein derived from pig tissue. Mederma is a topical gel that can reduce scarring. Integra consists of a two-layer membrane- one is a synthetic epidermal layer, and the other contains cross-linked collagen fibers that mimic the dermal layer of skin. TransCyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable membrane attached to nylon mesh.
An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?
- A. The client is in hypovolemic shock.
- B. The client has experienced extensive full-thickness burns.
- C. The paramedita administered high doses of opioids during transport.
- D. The client has experienced partial-thickness burns.
Correct Answer: B
Rationale: In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opoids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.