Question 1

During the immediate postburn period, the nurse conducts a rapid but thorough assessment. Which finding indicates a potential complication?

Accepted Answer

A

Question 2

The nurse is teaching a patient about the need for continued stretching exercises after discharge from burn treatment. The nurse evaluates that the patient understands what is necessary when the patient makes which statement?

Accepted Answer

Option D is the correct statement indicating that the patient understands the need for continued stretching exercises after discharge from burn treatment. Stretching exercise is a crucial component of rehabilitation of burn injuries as it helps improve or maintain range of motion in the affected area. Options A and B are incorrect because splints and blanching are not related to stretching exercises. Option C is incorrect because a progressive exercise program can improve overall stamina.

Question 3

Escharotomies have been performed on a patient's arms because of circumferential burn injuries. What is the nurse's highest assessment priority?

Accepted Answer

The highest assessment priority for a patient who has undergone an escharotomy is to assess circulation in the extremity distal to the escharotomy. The procedure involves making incisions through the burned tissue to relieve pressure caused by edema. This can compromise blood flow, and potential complications include circulation impairment, ischemia, and tissue necrosis distal to the incision site. Therefore, close monitoring of circulation is essential. While the formation of contractures, wound infection, and range-of-motion exercises are important considerations for a patient with burn injuries, they are not the highest priority in this scenario.

Question 4

A patient sustained a radiation injury in an accident at a nuclear power plant. Which assessment questions would the nurse ask to determine the depth of this injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of A patient sustained a radiation injury in...

Question 5

Which patient care goals does the nurse prioritize during the acute phase of burn treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of Which patient care goals does the nurse...

Question 6

A patient is scheduled to receive a meshed skin graft to begin closing a major burn injury. How would the nurse explain the rationale for using a meshed graft?

Accepted Answer

Meshing allows the graft to cover a larger area by creating a pattern of small holes in the graft, which allows it to expand and cover a larger surface area than an unmeshed graft. This is particularly beneficial in treating large burn injuries where a large area of skin needs to be replaced.

Question 7

The nurse is admitting a 25-year-old patient to the emergency department with partial-thickness injuries over 20% of the total body surface area, involving both lower legs. According to American Burn Association ABA) guidelines, the nurse would classify this as which level of burn?

Accepted Answer

The answer of The nurse is admitting a 25-year-old patient...

Question 8

During the acute period of burn care, a focus of care is to promote healing of full-thickness burn wounds. Which nursing interventions are necessary before this healing can begin?

Accepted Answer

Before healing of full-thickness burn wounds can begin, it is necessary to debride and cleanse the wound bed of eschar to remove dead tissue, debris, and bacteria. This allows for a clean, healthy environment for new tissue growth. The other options may be important for overall burn care, but are not necessary before healing can begin.

Question 9

The nurse is preparing a patient for discharge from the hospital following a major burn injury. The nurse would consider which pathophysiology when developing a plan for the patient's nutrition?

Accepted Answer

The hypermetabolic state, characterized by an increase in metabolic rate and catabolism of muscle and fat, can last for months following a major burn injury until all the wounds are healed. Therefore, the nurse should develop a plan for the patient's nutrition that takes into account their increased caloric and protein needs to support tissue healing and prevent muscle wasting. Additional oral fluids may be needed, but this is not the major dietary need after discharge. Calorie intake should not be decreased as the patient needs adequate nutrition for healing.

Question 10

The nurse would anticipate which laboratory result drawn 10 hours after a patient experienced a major burn injury?

Accepted Answer

After a major burn injury, fluid shifts from the intravascular space to the interstitial space, leading to hemoconcentration and an increased hematocrit level.

Question 11

The nurse has admitted a patient who sustained a partial-thickness burn injury of 28% of total body surface area TBSA) and a full-thickness injury of 30% of TBSA. Which American Burn Association ABA) classification would the nurse assign to this injury?

Accepted Answer

According to the ABA classification, burn injuries greater than 25% of TBSA are classified as major, while injuries between 15-25% are considered moderate. This patient's injuries exceed 25%, with 28% partial-thickness and 30% full-thickness burns, so the nurse would assign this injury a classification of major.

Question 12

A patient has sustained a burn injury to the anterior chest and neck and the right shoulder, arm, and hand. How should the nurse position this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of A patient has sustained a burn injury...

Question 13

The nurse is caring for a patient who was overexposed to radiation during cancer treatment. The nurse plans care with the knowledge that which cells are most susceptible to this type of radiation injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

Skin cells, gastrointestinal tract cells, and bone marrow cells are most susceptible to radiation injury because they have a high rate of cellular division and growth. Kidney cells and muscle cells have a lower rate of division, so they are less susceptible to radiation injury.

Question 14

Surrounding tissue destroyed by burn is an area identified as the zone of stasis. Which nursing interventions are designed to protect this zone from further damage? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

Strict adherence to infection control measures, elevation of the burned area, and managing fluid resuscitation are all nursing interventions aimed at protecting the zone of stasis from further damage. Early focus on feeding the patient and administration of medications to prevent myoglobin release from cells do not directly relate to protecting the zone of stasis.

Question 15

The nurse manager of a burn unit is conducting education for newly hired nurses. What factors would the manager point to as reducing the rate of survival among burn patients? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The nurse manager would point to a history of substance abuse, endocrine diseases, renal disease, and cardiac disease as factors that could reduce the rate of survival among burn patients. These comorbidities can affect the body's ability to heal and respond to treatment, making it more difficult to recover from burn injuries. Previous burn injury may also be a risk factor, but it is not listed among the options.

Question 16

Which information will the nurse collect to assist in the classification of a burn injury as minor, moderate, or major? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

To classify a burn injury as minor, moderate, or major, the nurse will collect information on the location of the burns on the body, the history of the event and location where the injury occurred, any concurrent injuries, and the causative agent. The time the injury occurred may also be collected for documentation purposes, but it does not directly assist in classification.

Question 17

Which grief reactions would the nurse discuss with a patient who is being discharged from the hospital after treatment for major burn injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of Which grief reactions would the nurse discuss...

Question 18

A patient who sustained a burn injury over 65% of the body is in the acute phase of care. The patient's preburn weight was 165 pounds. The nurse would work with the patient to achieve intake of ________ calories each day.

Accepted Answer

The answer of A patient who sustained a burn injury...

Question 19

The nurse is admitting a 50-year-old female who was involved in a car accident and whose only injuries were burns over 50% of her body. Identify the highest-priority nursing diagnosis for this patient.

Accepted Answer

Burns over 50% of the body can lead to significant loss of fluids and electrolytes, making Deficient Fluid Volume the highest-priority nursing diagnosis. Pain, coping, and body image concerns are also important, but ensuring adequate fluid balance is vital for this patient's survival.

Question 20

The mortality rate for burns is highest in the very young and in the elderly population. What factors put the very young at a higher risk? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The very young have a greater proportion of body surface area per amount of body mass, increasing the risk for fluid-volume loss and increasing the likelihood of hypovolemic shock. Infants and young children have an immature immune system with a weak antibody response, making them more susceptible to infections and complications. Burns tend to exacerbate previous medical problems in the very young, increasing the risk for mortality. Option B is incorrect because the very young have a faster healing rate than adults. Option E may be true but it is not a factor that puts the very young at a higher risk compared to other age groups.

Quiz 61: Caring for the Patient With Burn Injuries

During the immediate postburn period, the nurse conducts a rapid but thorough assessment. Which finding indicates a potential complication?

The nurse is teaching a patient about the need for continued stretching exercises after discharge from burn treatment. The nurse evaluates that the patient understands what is necessary when the patient makes which statement?

Escharotomies have been performed on a patient's arms because of circumferential burn injuries. What is the nurse's highest assessment priority?

A patient sustained a radiation injury in an accident at a nuclear power plant. Which assessment questions would the nurse ask to determine the depth of this injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

Which patient care goals does the nurse prioritize during the acute phase of burn treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

A patient is scheduled to receive a meshed skin graft to begin closing a major burn injury. How would the nurse explain the rationale for using a meshed graft?

The nurse is admitting a 25-year-old patient to the emergency department with partial-thickness injuries over 20% of the total body surface area, involving both lower legs. According to American Burn Association ABA) guidelines, the nurse would classify this as which level of burn?

During the acute period of burn care, a focus of care is to promote healing of full-thickness burn wounds. Which nursing interventions are necessary before this healing can begin?

The nurse is preparing a patient for discharge from the hospital following a major burn injury. The nurse would consider which pathophysiology when developing a plan for the patient's nutrition?

The nurse would anticipate which laboratory result drawn 10 hours after a patient experienced a major burn injury?

The nurse has admitted a patient who sustained a partial-thickness burn injury of 28% of total body surface area TBSA) and a full-thickness injury of 30% of TBSA. Which American Burn Association ABA) classification would the nurse assign to this injury?

A patient has sustained a burn injury to the anterior chest and neck and the right shoulder, arm, and hand. How should the nurse position this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

Surrounding tissue destroyed by burn is an area identified as the zone of stasis. Which nursing interventions are designed to protect this zone from further damage? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

Which information will the nurse collect to assist in the classification of a burn injury as minor, moderate, or major? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

Which grief reactions would the nurse discuss with a patient who is being discharged from the hospital after treatment for major burn injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

A patient who sustained a burn injury over 65% of the body is in the acute phase of care. The patient's preburn weight was 165 pounds. The nurse would work with the patient to achieve intake of ________ calories each day.

The nurse is admitting a 50-year-old female who was involved in a car accident and whose only injuries were burns over 50% of her body. Identify the highest-priority nursing diagnosis for this patient.

The mortality rate for burns is highest in the very young and in the elderly population. What factors put the very young at a higher risk? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.