Nokea
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.
You may also like to solve these questions
Which zone consists of the area where the injury is most severe and deepest?
- A. Coagulation
- B. Stasis
- C. Hyperemia
- D. Necrosis
Correct Answer: A
Rationale: The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury. Where the epidermis and dermis are only minimally damaged. There is no zone of necrosis.
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.
What action should a nurse perform to help reduce the accumulation of debris within the burn wound?
- A. Use powder-free sterile gloves.
- B. Use topical antimicrobial medications.
- C. Use cold comppresses or sponges.
- D. Use sterilized gauze swaps.
Correct Answer: A
Rationale: The healthcare team should wear powder-free sterile gloves when handling the burn wound to reduce the accumulation of debris within the wound that may complicate the healing. After the wound has been cleansed, topical antimicrobial medications are used to minimize the risk of infection. The particles or fiber from cold comppresses, sponges, or sterilized gauze swaps may add to the accumulation of debris if used on a burn wound.
Which is a disadvantage of surgical debridement?
- A. Scarring
- B. Bleeding
- C. Loss of function
- D. Contractures
Correct Answer: B
Rationale: A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.
A nurse is caring for a client with facial burns who is prescribed the open method treatment. What nursing intervention should the nurse perform?
- A. Administer a cold sponge bath to the client.
- B. Keep the client's room cool and airy.
- C. Place a bed cradle or sheets over the client.
- D. Place the client on a moist linen sheet.
Correct Answer: C
Rationale: The skin of the client with burn is sensitive to drafts and temperature changes; therefore, a bed cradle or sheets should be placed over the client. The room should be kept warm and humidified, not cool and airy. The client should be placed in isolation in a bed with sterile, dry linen. Whirlpool baths are prescribed to loosen the crust, or eschar, which forms over the wound. Sponge baths are not advisable because particles from the sponge may cause accumulation of debris within the burn wound. Moist linen sheets are not placed on clients anymore due to their cooling effect, and they can lead the client to work hard to maintain proper body temperature.