Nokea
The nurse reviews the pathophysiology of burns with students. It would be correct to state which hormone alterations occur during a major burn. Select all that apply.
- A. Increased secretion of epinephrine
- B. Increased secretion of antidiuretic hormone (ADH)
- C. Increased secretion of aldosterone
- D. Decreased levels of glucose
- E. Increased secretion of norepinephrine
Correct Answer: A, B, C, E
Rationale: Major burns cause a stress response, increasing epinephrine, ADH, aldosterone, and norepinephrine to compensate for fluid loss and maintain homeostasis. Glucose levels increase, not decrease, due to stress-induced hyperglycemia.
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The emergency department (ED) nurse is caring for a client who sustained a witnessed electrical burn
Item 1 of 1
Triage Note
Triage Vital Signs
1730: A 35-year-old male was brought to the emergency department (ED) by his father after they were working on electrical wiring at a residential house. The client's father witnessed his son grab a wire and sustain a significant 'jolt' for five to ten seconds. The client briefly lost consciousness and was disoriented immediately afterward. The client was immediately placed in the father's car and transported to the ED. A localized burn was noted on the client's right hand. Scant sanguineous drainage noted. The client reports pain of a '6' (0= no pain; 10= severe pain) that is worsened with movement. The client is alert and oriented to place and time; however, he does not recall the situation that brought him to the hospital. Glasgow
Coma Scale (GCS) 14. The client reports that he feels like his 'heart is intermittently skipping.'
The nurse is immediately concerned that the client is at risk for developing …………….. as evidenced by the client's ………………
- A. carbon monoxide poisoning
- B. wound infection
- C. cardiac dysrhythmias
- D. Glasgow Coma Scale
- E. pulse
- F. pain level
Correct Answer: C, E
Rationale: The client's report of feeling like his 'heart is intermittently skipping' indicates a potential cardiac dysrhythmia, which is a serious complication of electrical burns due to the effect of electrical current on the heart. The pulse is the finding that supports this concern.
The nurse is caring for a client who sustained an electrical burn. Which priority action should the nurse take?
- A. Obtain an electrocardiogram (ECG)
- B. Obtain an order for an arterial blood gas (ABG)
- C. Perform wound care
- D. Initiate supplemental oxygen
Correct Answer: A
Rationale: Electrical burns can cause cardiac dysrhythmias, so obtaining an ECG is the priority to assess heart rhythm.
The nurse is caring for a client with a major thermal burn. Which initial laboratory abnormalities does the nurse anticipate in response to the burn? Select all that apply.
- A. Hemodilution
- B. Hyperkalemia
- C. Metabolic Acidosis
- D. Hyperglycemia
- E. Hemoconcentration
Correct Answer: B, C, D, E
Rationale: Burns cause hyperkalemia (cell destruction), metabolic acidosis (tissue hypoxia), hyperglycemia (stress response), and hemoconcentration (fluid loss).
The nurse is caring for a client with incontinence-associated dermatitis. The nurse should take which action? Select all that apply.
- A. Cleanse the affected area with isopropyl alcohol
- B. Apply zinc oxide to the affected area
- C. Use an incontinence pad instead of a brief
- D. Applying an extra incontinence brief to encapsulate the moisture
- E. Apply a transparent dressing to the affected area
Correct Answer: B, C
Rationale: Zinc oxide protects the skin, and incontinence pads reduce moisture exposure. Alcohol is too harsh, extra briefs trap moisture, and transparent dressings are not suitable for this condition.
The wound care nurse is caring for a client at the outpatient clinic
Item 1 of 1
Nurses' Notes
Medical History
1300 - Client presents to the clinic on a referral from the primary healthcare provider for a wound to the right ankle area. The injury developed three months ago and has worsened despite topical treatment. On assessment, the wound is 5 cm x 4 cm and is shallow. The wound bed is pink with some granulation tissue; scant sanguineous drainage. Wound edges are uneven. Client reports pain only when dressing changes are performed, and the pain is rated as 5 on a scale of 0 (no pain) to 10 (severe pain). The surrounding skin on the affected foot is dry, darkened, and flaky. Capillary refill < 3 seconds. Peripheral pedal pulse 2+ on the affected foot. 3+ Ankle edema was noted in both lower extremities. The client denies leg pain during ambulation but endorses ankle swelling during the day while walking, and the only relieving factor is the application of a compression hose to both legs. The client reports applying a hot compress to the extremity but states after 2-3 applications, it worsened and became painful.
For each assessment finding below, click to specify if the finding is consistent with an arterial, venous, or diabetic ulcer. Each finding may support more than one (1) disease process.
- A. swelling in affected extremity
- B. pedal peripheral pulse 2+
- C. swelling relieved with compression hose
- D. denies leg pain during ambulation
- E. shallow wound bed
- F. medical history of hypertension and diabetes mellitus
- G. worsened with hot compress
Correct Answer: A: B, D, E, F; V: A, C, E; D: E, F, G
Rationale: Arterial ulcers: normal pulse, no leg pain, shallow wounds, and hypertension/diabetes history. Venous ulcers: swelling, compression relief, shallow wounds. Diabetic ulcers: shallow wounds, diabetes history, worsened with heat.