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While performing a patients ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patients behavior?
- A. The patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior.
- B. The patient may be experiencing neurologic or psychiatric complications of his injuries.
- C. The patient may be experiencing inconsistencies in the care that he is being provided.
- D. The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.
Correct Answer: D
Rationale: Anger is common in burn patients and may be deflected toward caregivers. Drug reactions, complications, or care inconsistencies are less likely without specific evidence.
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A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment?
- A. Monitoring fluid and electrolyte imbalances
- B. Providing education to the patient and family
- C. Treating infection
- D. Promoting thermoregulation
Correct Answer: B
Rationale: Education for the patient and family is a priority in the rehabilitation phase to support self-care and adjustment. Fluid imbalances, infection, and thermoregulation are addressed in the acute phase.
A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
- A. Early enteral feeding
- B. Administration of prophylactic antibiotics
- C. Bowel cleansing procedures
- D. Administration of stool softeners
Correct Answer: A
Rationale: Early enteral feeding supports the intestinal mucosal barrier, reducing permeability and preventing endotoxin translocation. Prophylactic antibiotics risk resistant bacteria, and bowel cleansing or stool softeners do not address this issue.
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
- A. Instruct the patient to keep the wound site in a dependent position.
- B. Administer PRN analgesia as ordered.
- C. Assess the patients peripheral pulses distal to the dressing.
- D. Assist with passive range of motion exercises to set the new dressing.
Correct Answer: C
Rationale: Checking peripheral pulses ensures dressings are not too tight, preventing circulatory compromise. Dependent positioning is avoided, analgesia is given before dressing changes, and ROM exercises are not typically post-dressing.
A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?
- A. To prevent neuropathies
- B. To prevent wound breakdown
- C. To prevent contractures
- D. To prevent heterotopic ossification
Correct Answer: C
Rationale: Maintaining joint alignment prevents contractures, a common complication of burns due to tissue shortening. It does not primarily prevent neuropathies, wound breakdown, or ossification.
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?
- A. Sodium deficit
- B. Decreased prothrombin time (PT)
- C. Potassium deficit
- D. Decreased hematocrit
Correct Answer: A
Rationale: Sodium deficit (hyponatremia) occurs in the emergent phase due to sodium loss in edema fluid. Potassium is elevated, hematocrit increases, and PT is not typically decreased.