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Burns NCLEX Question and Burn Injury Nursing Management Quiz #5 (20 Items)
In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?
- A. “Are you a smoker?”
- B. “When was your last chest x-ray?”
- C. “Have you ever had asthma or any other lung problem?”
- D. “In what exact place or space were you when you were burned?”
Correct Answer: D. “In what exact place or space were you when you were burned?”
The risk for inhalation injury is greatest when flame burns occur indoors in small, poorly ventilated rooms. The composition of smoke varies with each fire depending upon the materials being burned, the amount of oxygen available to the fire, and the nature of the fire. It is important to elucidate whether the exposure was to smoke, flames, and/or possible chemicals (both industrial and household). Duration of exposure, the location of exposure (such as if it was in an enclosed space), and any loss of consciousness are all important as well.
- Option A: Although smoking increases the risk for some problems, it does not predispose the client for an inhalation injury. History-taking should be complete and thorough. Burn patients may have extensive external injuries, but smoke inhalation may affect those with no outward signs of burns.
- Option B: Workup of smoke inhalation injury may include serial chest radiographs (often negative early in smoke inhalation injury) and computed tomography (CT) chest. A delay in the onset of symptoms is not uncommon, and clinicians should educate patients on the possibility of delayed symptom onset post-exposure. The delayed symptoms occur in the lower respiratory airways as it is caused by chemical toxin exposure, which may bypass the upper airways.
- Option C: Short-term complications are seen in more severe injuries within 4 to 5 days, and the most common issue is pneumonia. Acute respiratory distress syndrome and pulmonary edema are also seen in the short term.
Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?
- A. The client is able to talk.
- B. The client is alert and oriented.
- C. The client’s oxygen saturation is 97%.
- D. The client’s chest movements are uninhibited.
Correct Answer: C. The client’s oxygen saturation is 97%.
Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.
- Option A: A thorough respiratory assessment consists of inspection, palpation, percussion, and auscultation in conjunction with a comprehensive health history. Use a systematic approach and compare findings between left and right so the patient serves as his own control.
- Option B: Respirations should be even, unlabored, and regular at a rate of 12 to 20 breaths per minute. Normally, inspiration is half as long as expiration, and chest expansion is symmetrical. If the client appears anxious or exhibits nasal flaring, cyanosis of the lips and mouth, intercostal retraction, or use of accessory muscles of respiration, he may be in respiratory distress.
- Option D: Normally, the thorax is symmetrical and the anterior-posterior diameter is less than the transverse diameter. (Equal diameters may signal chronic obstructive pulmonary disease in an adult.) Note any structural deformity such as a pigeon chest (pectus carinatum) or funnel chest (pectus excavatum).
The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care?
- A. Emergent Phase
- B. Immediate Resuscitative Phase
- C. Acute Phase
- D. Rehabilitation Phase
Correct Answer: C. Acute Phase
The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care that includes wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting, pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections.
- Option A: The emergent phase begins with the onset of burn injury and lasts until the completion of fluid resuscitation or a period of about the first 24 hours. During the emergent phase, the priority of client care involves maintaining an adequate airway and treating the client for burn shock.
- Option B: Priorities during the immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care.
- Option D: The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.
The burned client’s family asks at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?
- A. “When fluid remobilization has started.”
- B. “When the burn wounds are closed.”
- C. “When IV fluids are discontinued.”
- D. “When body weight is normal.”
Correct Answer: B. “When the burn wounds are closed.”
Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at great risk for infection as long as any area of skin is open.
- Option A: Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute tubular necrosis). Once initial fluid resuscitation has been accomplished, a steady rate of fluid administration is preferred to boluses, which may increase interstitial fluid shifts and cardiopulmonary congestion.
- Option C: The important point to remember is the fluid amount calculated is just a guideline. Patient’s vital signs, mental status, capillary refill, and urine output must be monitored and fluid rates adjusted accordingly. Urine output of 0.5 mL/kg or about 30 – 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg is a good target for adequate fluid resuscitation. Recent literature has raised concerns about complications from over-resuscitation described as “fluid creep.” Again, adequate fluid resuscitation is the goal.
- Option D: Severe burn is associated with significant changes in body weight due to large resuscitation volumes, fluid shifts, a hypermetabolic state, prolonged bed rest, and caloric intake. Weight gain in the severely burned patient often follows initial fluid resuscitation, which can increase weight by up to 10–20 kg.
The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?
- A. Seasonal asthma
- B. Hepatitis B 10 years ago
- C. Myocardial infarction 1 year ago
- D. Kidney stones within the last 6 month
Correct Answer: C. Myocardial infarction 1 year ago
It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation. The initial response to severe burn injury or early shock state is characterized by a decrease in cardiac output and metabolic rate. The reduction in cardiac output is partially due to hypovolemia and reduced venous return.
- Option A: Systemic effects may occur especially after inhalation injury. Systemic effects of inhalation injury occur both indirectly from hypoxia or hypercapnia resulting from loss of pulmonary function and systemic effects of pro-inflammatory cytokines, as well as direct effects from metabolic poisons such as carbon monoxide and cyanide.
- Option B: A history of hepatitis B does not affect the fluid resuscitation plan. Fluid creep in patients recovering from acute burns still exists, despite the use of a more treatment conservative approach. Most severe burn patients develop fluid overload and body weight increase after acute fluid resuscitation. How to quickly return patients to their pre-injury body weight is an important issue
- Option D: Acute renal failure is one of the major complications of burns and it is accompanied by a high mortality rate. Most renal failures occur either immediately after the injury or at a later period when sepsis develops.
The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action?
- A. Assess level of consciousness and pupillary reactions.
- B. Ask the client at what time food or liquid was last consumed.
- C. Auscultate breath sounds over the trachea and mainstem bronchi.
- D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.
Correct Answer: C. Auscultate breath sounds over the trachea and mainstem bronchi.
Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client’s airway is in severe jeopardy and intubation is highly likely to be needed shortly. Close physical examination of patients with inhalation injury can reveal signs of smoke inhalation, including facial burns, perioral burns, and singed nasal hairs. This warrants laryngoscopy and evidence of significant edema, blisters, or ulcerations should lead to consideration for intubation to stabilize the airway.
- Option A: Neurovascular assessment may be done after establishing a patent airway. Inhalation of smoke also leads to the absorption of many toxins in the blood, including carbon monoxide and cyanide, thereby causing the entire body to be affected, and making inhalational injury a systemic insult.
- Option B: History taking can be done after the patient has been deemed stable. It is well known that rapid diagnosis and treatment are key when it comes to inhalational burns, as acute complications, which sometimes go unnoticed, are the reason behind long-term sequels and the high mortality rate seen with this type of injury.
- Option D: GI assessment is not a priority. Edema of the oral mucosa and/or the trachea can develop within 0.5 hours of the time of injury and can progress to mucosal necrosis within 12-24 hours. Supraglottic injury, swelling, and resulting obstruction of the airway occur more commonly in children due to the smaller size of the trachea, and relatively large epiglottis.
Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds?
- A. Handwashing on entering the client’s room
- B. Encouraging the client to cough and deep breathe
- C. Administering the prescribed tetanus toxoid vaccine
- D. Changing gloves between cleansing different burn areas
Correct Answer: A. Handwashing on entering the client’s room
Cross-contamination occurs when microorganisms from another person or the environment are transferred to the client. Handwashing with soap and water is the best way to get rid of germs in most situations. Emphasize and model good handwashing techniques for all individuals coming in contact with the patient.
- Option B: Although all the interventions listed above can help reduce the risk of infection, only handwashing can prevent cross-contamination. Airway obstruction and/or respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after a burn.
- Option C: Tissue destruction and altered defense mechanisms increase the risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity.
- Option D: Serious complications often can be avoided by following strict aseptic techniques. Use of a mask, hat, gown, and sterile gloves, and drapes during placement of central venous catheters (CVCs) should be strictly implemented.
In reviewing the burned client’s laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis?
- A. The total white blood cell count is 9000/mm3.
- B. The lymphocytes outnumber the basophils.
- C. The “bands” outnumber the “segs.”
- D. The monocyte count is 1,800/mm3.
Correct Answer: C. The “bands” outnumber the “segs.”
Normally, the mature segmented neutrophils (“segs”) are the major population of circulating leukocytes, constituting 55% to 70% of the total white blood count. Fewer than 3% to 5% of the circulating white blood cells should be the less mature “band” neutrophils. A left shift occurs when the bone marrow releases more immature neutrophils than mature neutrophils. Such a shift indicates severe infection or sepsis, in which the client’s immune system cannot keep pace with the infectious process.
- Option A: The normal WBC count is 4,500 to 11,000/mm3. Burn injury causes systemic inflammatory response. The magnitude of the changes is roughly a function of burn size that is manifested by increased body temperature, increased WBC count, and increased metabolic rate, which makes diagnosis of infection in the burned patient more difficult.
- Option B: Peripheral blood lymphocytes represent the most important line of host defense against pathogenic microorganisms in humans. Researchers found a reduction in the number of lymphocytes as well as WBC, which may contribute to the impairment of general mechanisms for immune regulation during burn shock and transition of blood to the level of self-regulation.
- Option D: The normal monocyte count ranges from 100-700 per mm3 (2–8%). Severe burn and sepsis profoundly inhibit the functions of DC, monocyte, and macrophage. These phagocytes are the first cellular responders to severe burn injury after acute disruption of the skin barrier.
The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?
- A. Place a towel roll under the client’s neck or shoulder.
- B. Keep the client in a supine position without the use of pillows.
- C. Have the client turn the head from side to side 90 degrees every hour while awake.
- D. Keep the client in a semi-Fowler’s position and actively raise the arms above the head every hour while awake.
Correct Answer: C. Have the client turn the head from side to side 90 degrees every hour while awake.
The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion. Deformities and contractures can often be prevented by proper positioning. Maintaining proper body alignment when the patient is in bed is vital. This movement is what would prevent contractures from occurring.
- Option A: Placing a towel roll under the neck might not help prevent contractures. Immobilization is only allowed when a part of the body has just been grafted. Even then, the area must be kept in an antideformity position.
- Option B: The client should not only be in a supine position but there should be a movement to avoid contractures. Splinting and proper positioning will also help achieve the prevention of contractures. As a matter of importance, movement should be incorporated into the patient’s daily routine from their inception to the hospital.
- Option D: The burns are in the client’s posterior neck. Performing active or passive range of motion (ROM) exercises, depending on the patient’s level of consciousness is crucial in the prevention of these complications.
The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintains to retain maximum function of this joint?
- A. Hip maintained in 30-degree flexion, no knee flexion
- B. Hip flexed 90 degrees and knee flexed 90 degrees
- C. Hip, knee, and ankle all at maximum flexion
- D. Hip at zero flexion with leg flat
Correct Answer: D. Hip at zero flexion with leg flat
Maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours at a time in this position, he or she should be in this position (in bed or standing) more of the time than with the hip in any degree of flexion.
- Option A: Anti-contracture positioning and splinting must start from day one and may continue for many months post-injury. Legs should be positioned in a neutral position ensuring that the patient is not externally rotating at the hips.
- Option B: When burns occur to the flexor aspect of a joint or limb the risk of contracture is greater. This is due to the position of comfort being a flexed position; also the flexor muscles are generally stronger than the extensors so should a burn occur to the extensor aspect, patients can use the strength of the flexors to stretch the particular area.
- Option C: Patients rest in a position of comfort; this is generally a position of flexion and also the position of contracture. Without ongoing advice and help with positioning, the patient will continue to take the position of contracture and can quickly lose ROM in multiple joints. Once contracture starts to develop it can be a constant battle to achieve full movement, so preventative measures to minimize contracture development are necessary.
During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?
- A. Increased wound pain 30 to 40 minutes after drug application
- B. Presence of small, pale pink bumps in the wound beds
- C. Decreased white blood cell count
- D. Increased serum creatinine level
Correct Answer: D. Increased serum creatinine level
Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored.
- Option A: Gentamicin does not stimulate pain in the wound. The gentamicin is prone to accumulate in the renal proximal tubular cells and can cause damage. Hence, mild proteinuria and reduction of the glomerular filtration rate are potential consequences of gentamicin use, achieving 14% of gentamicin users in a review.
- Option B: The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Renal function should be evaluated twice-weekly in patients without previous renal disease through serum creatinine and blood urea nitrogen. Periodic microscopic urinalysis is also vital to detect proteinuria and casts, which may indicate kidney injury.
- Option C: The possible hypersensitivity manifestations of gentamicin are urticaria, eosinophilia, delayed-type hypersensitivity reaction (Stevens-Johnson syndrome and toxic epidermal necrolysis), angioedema, and anaphylactic shock. The clinical manifestations should guide the treatment strategy.
The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse’s best action?
- A. Nothing, because the findings are normal for clients during the acute phase of recovery.
- B. Increase the temperature in the room and increase the IV infusion rate.
- C. Assess the client’s airway and oxygen saturation.
- D. Notify the burn emergency team.
Correct Answer: D. Notify the burn emergency team.
These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention. Invasive infection of burn wounds is a surgical emergency because of the high concentrations of bacteria (>105 CFU) in the wound and surrounding area, together with new areas of necrosis in unburned tissues.
- Option A: Invasive infection is now the chief reason for death and morbidity after burn injury, with it being responsible for 51% of the deaths. The importance of prevention, surveillance, and sampling for infections in this immunocompromised group has been well established; however, there is a dearth of standard-of-care guidelines and novel approaches.
- Option B: Urgent resuscitation measures are required, along with broad-spectrum antimicrobial agents, antifungals, and surgical debridement of the affected area. Specimens of this tissue must undergo histopathologic and microbiologic analysis to assist in the identification of the causative organism(s).
- Option C: Assessment of the airway and oxygen saturation would not help in diagnosing a burn infection. Burn wound colonization may be diagnosed when bacteria are present at low concentrations (<105 colony-forming units [CFU]) on the wound’s surface. This situation often is accompanied by signs of sepsis and changes in the burn wound such as black, blue, or brown discoloration of the eschar.
Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?
- A. Changing gloves between wound care on different parts of the client’s body.
- B. Avoiding sharing equipment such as blood pressure cuffs between clients.
- C. Using the closed method of burn wound management.
- D. Using proper and consistent handwashing.
Correct Answer: A. Changing gloves between wound care on different parts of the client’s body.
Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body, causing infection of a previously uninfected area. Use gowns, gloves, masks, and strict aseptic techniques during direct wound care and provide sterile or freshly laundered bed linens or gowns.
- Option B: Although all techniques listed can help reduce the risk of infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination. Depending on the type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from a simple wound and/or skin to complete or reverse to reduce the risk of cross-contamination and exposure to multiple bacterial flora.
- Option C: Prevent skin-to-skin surface contact (wrap each burned finger or toe separately; do not allow burned ear to touch scalp). This identifies the presence of healing (granulation tissue) and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury.
- Option D: Emphasize and model good handwashing techniques for all individuals coming in contact with the patient. This prevents cross-contamination and reduces the risk of acquired infection.
When should ambulation be initiated in the client who has sustained a major burn?
- A. When all full-thickness areas have been closed with skin grafts
- B. When the client’s temperature has remained normal for 24 hours
- C. As soon as possible after wound debridement is complete
- D. As soon as possible after the resolution of the fluid shift
Correct Answer: D. As soon as possible after the resolution of the fluid shift
Regular, progressive ambulation is initiated for all burn clients who do not have contraindicating concomitant injuries as soon as the fluid shift resolves. Clients can be ambulated with extensive dressings, open wounds, and nearly any type of attached lines, tubing, and other equipment.
- Option A: The consistent finding in the literature is that early ambulation can be safely initiated after lower extremity skin grafting without compromising graft take if external compression is applied.
- Option B: Following thermal injury, the innate immune system responds immediately by stimulating localized and systemic inflammatory reactions. The innate immune response participates in activating the adaptive immune response; however, in so doing it has an adverse effect on the burn victim’s ability to mount a vigorous immune response to invading microorganisms and, therefore, predisposes the burn victim to infectious complications.
- Option C: Pain control is obtainable by performing therapies during wound dressing and debridement, if possible. Analgesics should also be administered prior to therapy sessions to encourage participation in movement activities.
What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures?
- A. “For the first few days after surgery, the donor sites will be painful.”
- B. “Because the graft is my own skin, there is no chance it won’t ‘take’.”
- C. “I will have some scarring in the area when the skin is removed for grafting.”
- D. “Once all grafting is completed, my risk for infection is the same as it was before I was burned.”
Correct Answer: B. “Because the graft is my own skin, there is no chance it won’t ‘take’.”
Factors other than tissue type, such as circulation and infection, influence whether and how well a graft “takes.” The client should be prepared for the possibility that not all grafting procedures will be successful. Graft survival depends on the diffusion of nutrients and oxygen from the wound bed known as imbibition. Inosculation then follows when the blood vessels of the graft and from the wound bed grow together to make end-to-end contact. Lastly, neovascularization occurs when new blood vessels grow from the wound bed into the graft.
- Option A: The donor sites will be painful after the surgery. Silicone gel sheets, along with pressure dressings, have shown a dramatic decrease in pain, pruritus, and scar thickness six months after burn injury.
- Option C: There can be scarring in the area where the skin is removed for grafting. Burn scars are a common occurrence after skin grafting and can cause anxiety, depression, pain, itching, altered pigmentation, temperature intolerance, and decreased range of motion secondary to scar contracture. Scar formation is propagated by deficiencies in the biosynthetic and tissue degradation pathway during wound healing.
- Option D: The client is still at risk for infection. Early failure of graft survival is attributable to seroma and hematoma formation, which lifts the graft off the wound bed, preventing imbibition. Other factors that lead to graft failure include shearing forces, edematous tissue, and infected tissue.
Which statement by the client indicates a correct understanding of rehabilitation after burn injury?
- A. “I will never be fully recovered from the burn.”
- B. “I am considered fully recovered when all the wounds are closed.”
- C. “I will be fully recovered when I am able to perform all the activities I did before my injury.”
- D. “I will be fully recovered when I achieve the highest possible level of functioning that I can.”
Correct Answer: D. “I will be fully recovered when I achieve the highest possible level of functioning that I can.”
Although a return to pre-burn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound closure and ends when the client returns to her or his highest possible level of functioning.
- Option A: Rehabilitation of burns patients is a continuum of active therapy starting from admission. There should be no delineation between an ‘acute phase’ and a ‘rehabilitation phase’ as this idea can promote the inequality of secondary disjointed scar management and/or functional rehabilitation teams.
- Option B: The final stage in caring for a patient with a burn injury is the rehabilitative stage. This stage starts with the closure of the burn and ends when the patient has reached the optimal level of functioning. The focus is on helping the patient return to a normal injury-free life. Helping the patient adjust to the changes the injury has imposed is also a priority.
- Option C: Early compliance is essential to ensure the best possible long-term outcome and also to ease pain and assist with exercise regimes. Patients need to adhere to a positioning regime in the early stages of healing and this takes teamwork and dedication.
Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates a correct understanding of the purpose of this treatment?
- A. “After this treatment, my ears will not stick out.”
- B. “The mask will help protect my skin from sun damage.”
- C. “Using this mask will prevent scars from being permanent.”
- D. “My facial scars should be less severe with the use of this mask.”
Correct Answer: D. “My facial scars should be less severe with the use of this mask.”
The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Hypertrophic burn scars pose a challenge for burn survivors and providers. In many cases, they can severely limit a burn survivor’s level of function, including work and recreational activities.
- Option A: The pressure garment will not change the angle of the ear attachment to the head. By applying pressure to the burn or scar, the face mask keeps the skin soft and flat during the scar-forming phase of healing. It helps the face heal with the least amount of scarring. The transparent face mask is worn 18-20 hours every day for 8 months to 2 years until the skin graft is mature.
- Option B: Although the mask does provide protection of sensitive newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. A widespread modality of prevention and treatment of hypertrophic scarring is the utilization of pressure garment therapy (PGT).
- Option C: Scars will still be present. This treatment modality continues to be a clinically accepted practice. It is the most common therapy used for the treatment and prevention of abnormal scars after burn injury particularly in North America, Europe, and Scandinavia where it is considered routine practice and regarded as the preferred conservative management with reported thinning and better pliability ranging from 60% to 85%.
What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury?
- A. Acute Pain
- B. Impaired Adjustment
- C. Deficient Diversional Activity
- D. Imbalanced Nutrition: Less than Body Requirements
Correct Answer: B. Impaired Adjustment
Recovery from a burn injury requires a lot of work on the part of the client and significant others. Seldom is the client restored to the preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client.
- Option A: By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem. This stage starts with the closure of the burn and ends when the patient has reached the optimal level of functioning. The focus is on helping the patient return to a normal injury-free life. Helping the patient adjust to the changes the injury has imposed is also a priority.
- Option C: Diversional activity for pain is applicable during the intermediate phase of the burn injury. Provide diversional activities appropriate for age and condition. This helps lessen concentration on pain experience and refocus attention.
- Option D: Imbalanced nutrition is more appropriate during the emergent and intermediate phases of the burn injury. Appropriate guides to proper caloric intake include 25 kcal/kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As the burn wound heals, the percentage of burned areas is reevaluated to calculate prescribed dietary formulas, and appropriate adjustments are made.
Nurse Faith should recognize that fluid shift in a client with burn injury results from an increase in the:
- A. Total volume of circulating whole blood
- B. Total volume of intravascular plasma
- C. Permeability of capillary walls
- D. Permeability of kidney tubules
Correct Answer: C. Permeability of capillary walls
In burn, the capillaries and small vessels dilate, and cell damage causes the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
- Option A: The steady intravascular fluid loss due to these sequences of events requires sustained replacement of intravascular volume in order to prevent end-organ hypoperfusion and ischemia. Reduced cardiac output is a hallmark in this early post-injury phase.
- Option B: Increase in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and plasma proteins between the intravascular and interstitial spaces. Subsequently, intravascular hypovolemia and haemoconcentration develop and maximum levels are reached within 12 hours after injury.
- Option D: Disruption of sodium-ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary permeability.
Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:
- A. Maintain room humidity below 40%
- B. Place top sheet on the client
- C. Limit the occurrence of drafts
- D. Keep room temperature at 80 degrees
Correct Answer: C. Limit the occurrence of drafts
A client with burns is very sensitive to temperature changes because heat is lost in the burn areas. Changes in location, character, intensity of pain may indicate developing complications (limb ischemia) or herald improvement and/or return of nerve function and sensation.
- Option A: Maintain comfortable environmental temperature, provide heat lamps, heat-retaining body coverings. Temperature regulation may be lost with major burns. External heat sources may be necessary to prevent chilling.
- Option B: Cover wounds as soon as possible unless open-air exposure burn care method is required. Temperature changes and air movement can cause great pain to exposed nerve endings.
- Option D: The major burn patient needs a body temperature greater than 37 – 37.5ºC to reach 38.5ºC, to avoid critical temperature and decrease energy expenditure, controlling hypercatabolic state. The recommended ambient temperature in large burn units is between 28 and 33ºC.