Nokea
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 1 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Which two (2) assessment findings is the nurse most concerned with?
Correct Answer: B, E
Rationale: The extent of injury (full- and partial-thickness burns) and loss of sensation in the right arm (indicating possible nerve damage) are critical concerns requiring immediate attention.