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Terms in this set (10)Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temperature at 140F c. Encourage regular home fire exit drills Rationale: A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Hot water heaters set at 140° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used. Supervision of older adults who are cooking is necessary if cognitive impairment is present. The injury that is least likely to result in a full-thickness burn is a. sunburn a. sunburn Rationale: Full-thickness burns may be caused by contact with flames, scalding liquids, chemicals, tar, or electrical current. When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters a. blisters Rationale: The appearance of partial-thickness (deep) burns may include fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema. A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is he most appropriate for the nurse to take next? a. Encourage the patient to cough and auscultate the lungs again d. Anticipate the need for endotracheal intubation and notify the physician Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide (CO). The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress. Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls c. sequestering of sodium and water in interstitial fluid Rationale: During the emergency phase, sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases. To maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, high-carbohydrate diet a. eat a high-protein, high-carbohydrate diet Rationale: The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delays in healing. A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the
wound bed b. observe the wound for signs of infection during dressing changes Rationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis. Pain management for the burn patient is most effective when (select all that apply) a. a pain rating tool is used to monitor the patient's level of pain a. a pain rating tool is used to monitor the patient's level of pain Rationale: The use of a pain rating tool assists the nurse in the assessment, monitoring, and evaluation of the pain management plan. The more control the patient has in managing the pain, the more successful the chosen strategies are. A selected variety of medications offer better pain relief for patients with burns, whose pain can be both continuous and treatment related over varying periods of time. It is not realistic to promise a patient that pain will be completely eliminated. It is not realistic to suggest that pain will be managed (during any phase of burn care) with nonpharmacologic pain management. Such management is meant to be adjuvant and individualized. A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a. applying pressure garments a. applying pressure garments Rationale: Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments. A patient is recovering from second- and third-degree burns over 30% of his body and the burn care team is planning for discharge. The first action the nurse should take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain
medications c. review the patient's current health care status and readiness for discharge to home Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The burn care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge Sets with similar termsMed Surg Exam 3 Burns Questions26 terms meg_jones2 Chapter 25 Burns NCLEX style questions with ration…26 terms lynnlacourse **Final Self assessment36 terms Moogle_Gone_Kupo Med Surg Week 2100 terms Joanne-Weaver Sets found in the same folderChapter 24 Burns27 terms IyaPraise End of Chapter Questions Lewis Med Surg 55-6050 terms lindsay_van_allen Chapter 61: assessment of the musculoskeletal syst…8 terms Keely_Davis28 Med Surg Ch 57 Intracranial Problems50 terms nkobs Other sets by this creatorAnatomical Descriptive Terms15 terms Clare_Keffer Drug Side Effects28 terms Clare_Keffer Medication Instructions31 terms Clare_Keffer Allergy History9 terms Clare_Keffer Other Quizlet setsImmunology Exam 3173 terms roabdel627 Bio Final19 terms b_less Study74 terms marcus44tmv Related questionsQUESTION What are FDA-approved medications for weight loss? 10 answers QUESTION A 90-year-old patient with hypermagnesemia is seen in the emergency department (ED). The ED nurse prepares the patient for admission to which inpatient unit? 15 answers QUESTION A patient with a blood pressure of 210/100 mm Hg would be expected to have a pulse that is: 15 answers QUESTION what are the 3 suture lines? 10 answers What are fullFull-thickness burns (was third degree) extend through and destroy all layers of the dermis and often injure the underlying subcutaneous tissue. Deep burn injury (was fourth degree) extends into underlying soft tissue and can involve muscle and/or bone.
What are the symptoms of full thickness burn types?Common symptoms of full-thickness burns may lead to:. skin discoloration, which can include the skin becoming: white. grey. black. brown. yellow.. skin appearing. dry. leathery. waxy.. swelling.. a lack of pain due to damage to nerve endings.. Which best describes a full thickness third degree burn?Full-thickness burn definition
Full-thickness burns are third-degree burns. With this type of burn, all layers of the skin — epidermis and dermis — are destroyed, and the damage may even penetrate the layer of fat beneath the skin. It's common to find all three types of burns within the same wound.
What is the difference between partial thickness and fullThicker burns, called superficial partial-thickness and deep partial-thickness burns (also called second-degree burns), have blisters and are painful. Full-thickness burns (also called third-degree burns) cause damage to all layers of the skin. The burned skin looks white or charred.
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The injury that is least likely to result in a full-thickness burn is
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