Chapter 50: Management of Clients with Burn Injury Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 50: Management of Clients with Burn Injury

MULTIPLE CHOICE

1. The nurse would explain to a client that when a major burn occurs, the bodys initial systemic responses include

a.

elevated pulse rate, decreased cardiac output, and polyuria.

b.

increased capillary permeability, decreased cardiac output, and oliguria.

c.

plasma leakage into surrounding tissue, decreased hematocrit, and oliguria.

d.

production of epinephrine, vasodilation, and increased cardiac output.

ANS: B

Immediately following a burn injury, vasoactive substances are released from the injured tissues. These substances initiate changes in capillary integrity, allowing plasma to seep into surrounding tissues. Direct heat injury to vessels further increases capillary permeability, which permits sodium ions to enter the cell and potassium ions to exit. Overall, this creates an osmotic gradient, which leads to increases in intracellular and interstitial fluid volumes and further depletion of intravascular fluid volume.

DIF: Comprehension/Understanding REF: pp. 1241-1242, 1243

OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. The nurse would perform close respiratory assessment for a client with inhalation injuries because lung tissue injury resulting from inhalation of smoke is caused by

a.

anoxia from lowered blood oxygen content.

b.

carbon monoxide poisoning.

c.

chemical action on lung tissues.

d.

heat damage from superheated air.

ANS: C

Smoke poisoning results from the inhalation of the by-products of combustion: noxious chemicals and particulate matter. The pulmonary response includes a localized inflammatory reaction, a decrease in bronchial ciliary action, and a decrease in alveolar surfactant.

DIF: Comprehension/Understanding REF: p. 1243 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

3. The nurse is caring for a client with burns covering the entire surface of both arms and the anterior trunk. Using the rule of nines, the nurse would estimate the percentage of burn surface area to be

a.

18%.

b.

27%.

c.

36%.

d.

45%.

ANS: C

Each arm accounts for 9% and the anterior trunk for 18% of body surface area.

DIF: Application/Applying REF: pp. 1247-1248

OBJ: Assessment

MSC: Physiological Integrity Reduction in Risk Potential-System Specific Assessments

4. A client admitted to the emergency department (ED) with burns of the chest and neck exhibits a wet, shiny, weeping surface with some blistering. The nurse would document these burn injuries as

a.

full thickness, fourth degree.

b.

full thickness, third degree.

c.

partial thickness, second degree.

d.

superficial, first degree.

ANS: C

Second-degree partial-thickness burns appear wet or blistered and are extremely painful but can heal without intervention (i.e., skin grafting) if they are small and do not become infected. A superficial, first-degree burn is red and painful, and looks like a sunburn. Full-thickness third-degree burns appear dry; perhaps mottled; and black, brown, white, or red in color. It is usually painless directly on the burn. The full-thickness fourth-degree burn appears charred and the burned part may be completely burned away.

DIF: Application/Applying REF: pp. 1243-1244

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

5. When caring for a severely burned client, the nurse notes that the clients urine is dark brown. The priority action by the nurse would be to

a.

check the urinary catheter for patency and irrigate it if needed.

b.

monitor vital signs more frequently to detect hypovolemia.

c.

notify the physician immediately and request an order for urinalysis.

d.

titrate intravenous (IV) fluids to maintain urine output of 75-100 ml/hour.

ANS: D

The nurse should administer IV fluids at a rate that maintains a urine output of 75-100 ml/hour. Myoglobin and hemoglobin released from the damaged muscles and red blood cells (hemachromogens) all can precipitate in the renal tubules and create acute tubular necrosis. Therefore they need to be vigorously flushed from the body. Checking the urinary catheter for patency is never a wrong intervention, the physician does need to be notified, the nurse may need to request a UA, but the priority action remains titrating the IV fluid rate.

DIF: Analysis/Analyzing REF: p. 1254 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

6. A client has a circumferential third-degree burn on the upper left arm. The nursing assessments specific for this client would include

a.

assessing capillary refill in the left hand.

b.

evaluating left hand strength.

c.

measuring left forearm circumference.

d.

monitoring blood pressure in the left arm.

ANS: A

Circulatory compromise may occur in the case of a circumferential burn. Therefore frequent assessment of distal extremity perfusion is necessary. Since it is circulation that may be compromised, tests of muscle strength are not specifically needed. Measuring circumference is not a routine assessment and blood pressure would need to be taken in the other arm.

DIF: Application REF: pp. 1248, 1254 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

7. A 200-pound client is receiving fluid replacement in the emergency department after 35% of the clients body was burned. The nurse would anticipate fluid resuscitation of at least

a.

140 ml/hour.

b.

14,000 ml in 24 hours.

c.

63 ml/hour.

d.

6364 ml in 24 hours.

ANS: D

The most widely used formula for burn resuscitation is 2-4 ml kg TBSA. This amount is given over the first 24 hours starting from the actual time of the burn. The initial solution used is lactated Ringers solution.

DIF: Application/Applying REF: pp. 1250-1251, 1256

OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Dosage Calculation

8. The nurse doing a home safety assessment would conclude that the client at highest risk for burns sustained from clothing ignition during meal preparation is

a.

an 18-month-old toddler.

b.

a 5-year-old child.

c.

a 15-year-old teenager.

d.

a 75-year-old adult.

ANS: D

Clothing ignition during routine meal preparation has been cited as a leading cause of burn injury, particularly in the older adult population.

DIF: Comprehension/Understanding REF: p. 1240 OBJ: Assessment

MSC: Safe, Effective Care Environment Safety and Infection Control-Home Safety

9. The nurse teaching a class on burn injury prevention would stress that the leading cause of fire deaths is

a.

children playing with matches.

b.

cigarettes igniting furniture.

c.

kitchen fires igniting other combustibles.

d.

space heaters igniting clothing.

ANS: B

Cigarette-related ignition of furniture and mattresses is the leading cause of fire deaths. Prevention efforts have focused on requiring manufacturers to design cigarettes with a lower propensity for ignition.

DIF: Comprehension/Understanding REF: p. 1240 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Home Safety

10. The nurse would assess that the client with a major burn is

a.

60 years old with a 20% burn.

b.

32 years old with a 14 % burn.

c.

18 years old with an 18% burn.

d.

10 years old with a 15% burn.

ANS: A

The classification of major burns follows: persons over age 40 with a 20% burn, persons under 40 with a 25% burn, children under 10 with a 20% burn. Other criteria include the following: burns involving the face, eyes, ears, hands, feet, and perineum likely to result in functional or cosmetic disability; high-voltage electrical burn injury; all burn injuries with concomitant inhalation injury or major trauma.

DIF: Comprehension/Understanding REF: p. 1259 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential: System Specific Assessments

11. When admitting a client who has sustained a burn injury, the nurse would inoculate against tetanus if the client has

a.

been inoculated in the last 6 years.

b.

open wounds with copious debris embedded.

c.

second-degree burns with broken blisters.

d.

third-degree burns.

ANS: B

Clients previously immunized against tetanus but not in the past 5 years should receive a tetanus toxoid booster.

DIF: Application/Applying REF: p. 1252 OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Immunizations

12. The nurse would assure a family member that for the first 24 hours after a burn injury, pain is kept to a minimum by administering

a.

intravenous narcotic agents.

b.

liquid narcotics via a nasogastric tube.

c.

narcotics via an intramuscular route into nonburned tissue.

d.

tepid soaks and oral morphine.

ANS: A

Pain management is achieved through administration of IV narcotic agents, typically morphine sulfate. The intramuscular or subcutaneous routes are not used because absorption from the soft tissues is unreliable during the emergent period, when peripheral perfusion is sporadic.

DIF: Comprehension/Understanding REF: p. 1251 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Pain Management

13. The nurse caring for a burn client would monitor the clients stools for occult blood as assessment for development of

a.

bleeding caused by bowel distention.

b.

gastric irritation related to smoke.

c.

intestinal ileus.

d.

stress ulcers.

ANS: D

With the reduction in blood flow to the gastric mucosa, ischemic changes to the upper gastrointestinal (GI) tract occur, resulting in small, superficial erosions to the stomach and duodenum. If left untreated, these erosions can progress to ulcerations (e.g., Curlings) and GI bleeding.

DIF: Application/Applying REF: p. 1262 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential: System Specific Assessments

14. The nurse caring for a client with burns over 40% of the body notes a hematocrit of 55% at 12 hours after the injury. The nurse would explain that this finding is related to

a.

cellular debris from burned tissue.

b.

decreased intravascular fluid.

c.

increased red blood cell (RBC) production.

d.

presence of carboxyhemoglobin (COHb).

ANS: B

Hematocrit levels are elevated in the first 24 hours after burn injury, demonstrating hemoconcentration from the loss of intravascular fluid. If the intravascular space is not replenished with IV fluids, hypovolemic shock ensues and ultimately death.

DIF: Analysis/Analyzing REF: p. 1244 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

15. A client suffered what seems to be a moderate electrical burn from contact with household electricity. However, the physician wants to admit the client for monitoring. When questioned about this decision, the best answer by the nurse is

a.

I am not sure but I can find out for you.

b.

It is our protocol that all electrical burns get admitted.

c.

With household current, there is great risk of cardiac rhythm problems.

d.

You need to be watched for fractures that can occur under normal use.

ANS: C

Household current is AC (alternating current) and is associated with cardiopulmonary arrest, ventricular fibrillation, tetanic muscle contractions, and long bone or vertebral compression fractures. Clients with electrical burns are considered to have a major burn injury and need admission to monitor for the development of dysrhythmias. If the nurse does not know the answer to a clients question, option a is a good answer. Option b is not the best because it does not give the client appropriate information and also refers to the client as an electrical burn instead of a client with an electrical burn. The fractures that occur with electrical burns occur during the electrocution process, not later in the course of recovery.

DIF: Comprehension/Understanding REF: p. 1241 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential: System Specific Assessments

16. The nurse would stress to the ancillary staff that the most important means of preventing the spread of infection in the burn unit is

a.

prophylactic antibiotics.

b.

restricting visitors with respiratory tract infections.

c.

strict hand-washing.

d.

using clean gowns, gloves, and masks.

ANS: C

Strict hand-washing is stressed to reduce the incidence of cross-contamination between clients and is the most important means of preventing the spread of infection. Visitors who are ill will be restricted and gowns, masks, and gloves will be used by staff, but the most important measure still remains good hand-washing.

DIF: Comprehension/Understanding REF: p. 1255 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Medical and Surgical Asepsis

17. The physician orders 1% silver sulfadiazine cream applied to a clients burn wound two times daily. The nurse would be aware that this medication can affect

a.

blood pH.

b.

hemoglobin level.

c.

serum electrolyte levels.

d.

white blood cell count.

ANS: D

Transient leukopenia typically appears after 2 or 3 days of treatment with silver sulfadiazine cream.

DIF: Comprehension/Understanding REF: p. 1258 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Effects/Contraindications

18. A clients burn wound is being treated with enzymatic debridement. At this time the nurse would assess the client for

a.

allergic reactions.

b.

bleeding from the burn wound.

c.

increased fluid loss.

d.

serum electrolyte imbalances.

ANS: B

Enzymatic debridement involves the application of commercially prepared proteolytic and fibrinolytic topical enzymes to the burn wound, which facilitates eschar removal. As the enzyme digests necrotic tissue, it also opens up thrombosed blood vessels. This results in some oozing of blood from the vessels, as well as a site for bacteria to enter the bloodstream.

DIF: Application/Applying REF: p. 1257 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

19. To reduce contractures of the knee in a client with extensive burns of the knee and mid-leg, the nurse would position the client with the knee

a.

extended.

b.

flexed.

c.

adducted.

d.

abducted.

ANS: A

Clients with burns of the knee should be positioned supine with knees extended (toes should be pointing toward ceiling).

DIF: Application REF: p. 1261 OBJ: Intervention

MSC: Physiological Integrity

20. The nurse teaching a home safety course would emphasize that because of growth and development factors, toddlers are most at risk for burn injuries caused by

a.

cigarettes.

b.

electricity.

c.

flame.

d.

scald.

ANS: D

Toddlers suffer more scald burn injuries than do any other age group. Causes include overturned coffeepots, cooking pans spilling hot liquid and grease, and bathing in too hot water. Some contributing causes include their curiosity, poor coordination, and lack of judgment.

DIF: Comprehension/Understanding REF: p. 1240 OBJ: Assessment

MSC: Physiological Integrity

21. To minimize hypertrophic scarring of a clients burn wound, the nurse would anticipate providing which intervention?

a.

Applying continuous pressure with elastic wraps

b.

Applying topical antimicrobial agents

c.

Debridement with enzymatic products

d.

Vigorous removal of all dead tissue

ANS: A

Hypertrophic scarring, which results from an overabundant deposition of collagen in the healed burn wound, can be minimized with the use of massage and pressure therapy. Constant pressure applied to healing burn wounds reduces the scarring process.

DIF: Application/Applying REF: p. 1266 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

22. A client has received a meshed split-thickness skin graft for coverage of a burn wound. The nurse would explain that the graft is meshed in order to

a.

allow fluid to escape from the wound.

b.

avoid the need for sutures to hold the graft in place.

c.

facilitate debridement of the wound.

d.

observe the wound more carefully.

ANS: A

Meshing permits coverage of larger areas or irregularly shaped wounds and allows for drainage from a bleeding wound bed.

DIF: Comprehension/Understanding REF: p. 1264 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

23. Using the Curreri formula to compute daily caloric needs of a 200-pound client with a 20% burn, the nurse-practitioner would compute the clients daily caloric needs to be

a.

2272.

b.

2580.

c.

2872.

d.

3072.

ANS: D

DIF: Application/Applying REF: p. 1261 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Nutrition and Oral Hydration

24. The ambulatory pediatric nurse teaching parents about prevention of burn injury would emphasize that the leading cause of burn injury for toddlers is

a.

contact with scalding liquids.

b.

open flames, including space heaters.

c.

playing with matches.

d.

touching hot radiators.

ANS: A

Contact with scalding liquids is the leading cause of burn injury in toddlers (children 2 to 4 years of age), who sustain more scald injuries than any other age group.

DIF: Comprehension/Understanding REF: p. 1240 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Home Safety

25. The nurse would know that goals for the diagnosis Disabled Family Coping have been met when the family of a burn-injured client

a.

asks frequent questions of all the staff.

b.

begins to interact with the local burn support group.

c.

insists on participating in the clients care.

d.

only comes to visit when the client requests.

ANS: B

Normal coping mechanisms may be overwhelmed in the family of a burned client. Outcomes for this diagnosis include showing appropriate coping strategies by verbalizing realistic expectations, expressing knowledge of the treatment regimen, interacting appropriately, and demonstrating decreased stress. Options a and c show a family that is still fearful and demanding. Option d shows a family in denial or perhaps one that is too overwhelmed to visit. Interacting with someone from the local burn survivors support group can give the family factual information plus demonstrates appropriate coping.

DIF: Analysis/Analyzing REF: p. 1264 OBJ: Evaluation

MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

26. The nurse dismissing a burn-injured client would evaluate that teaching goals have been met when the client says I

a.

have to avoid any moisturizers on the burns so they toughen up.

b.

cant wait to go home and throw out these pressure garments!

c.

should use only alcohol-free skin moisturizers.

d.

will need to wear sunscreen for at least a year.

ANS: C

Self-care measures after discharge include: proper wound care and dressing changes if applicable, applying alcohol-free moisturizer on healed burns and donor sites three times daily, avoiding sunlight completely for 1 year, and wearing the pressure dressings or garments 23 hours a day.

DIF: Evaluation/Evaluating REF: p. 1268 OBJ: Evaluation

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

27. A client was found unconscious in a burning wooden shed and is admitted to the intensive care unit. The client is tachypneic and restless, with a respiratory rate of 32 breaths/min. The clients oxygen saturation is 99%. The most appropriate action by the nurse is to

a.

administer morphine for both pain and anxiety control.

b.

apply oxygen at 2 L by nasal cannula.

c.

check the oximeter to see if it is working.

d.

request the physician order a carboxyhemoglobin level.

ANS: D

Carbon monoxide (CO) is produced by incomplete combustion of organic substances (e.g., wood or coal). It has an affinity for hemoglobin that is 200 times that of oxygen and will preferentially bind with hemoglobin when present. The result is tissue hypoxia. This client has a high risk for exposure to CO and is exhibiting signs of hypoxia. The nurse should request the physician order a carboxyhemoglobin level. If asphyxiation with CO is suspected, oxygen needs to be administered at 100% via a non-rebreathing facemask. Pulse oximetry will be unreliable in cases of CO poisoning.

DIF: Analysis/Analyzing REF: p. 1242 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

MULTIPLE RESPONSE

1. To best meet the psychological needs of a burned client in the acute phase of burn care, the nurse would (Select all that apply)

a.

administer tranquilizers when the client is out of control.

b.

assist the client to control destructive behaviors.

c.

involve the family as much as they and the client desire and are able.

d.

offer factual information about the appearance of burns.

e.

provide an atmosphere that accepts emotional lability.

ANS: B, C, D, E

During the acute phase the client recognizes the extent of injury and realizes that his/her body is changed forever, leading to the diagnosis Disturbed Personal Identity. Nurses can assist clients through this stage by expecting and accepting emotional lability while assisting the client to control destructive behaviors. Allowing family members to be involved in care is helpful also. Staff members should be able to supply information on the appearance of the burns and expected changes that will occur over time.

DIF: Application/Applying REF: p. 1263 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Unexpected Body Image Changes

2. A severely burn-injured client is being discharged at the end of the week. Important interventions the nurse can provide to assist the client with re-integration into society include (Select all that apply)

a.

down-playing the appearance of the burned areas to prevent discouragement.

b.

encouraging the client to interact with people outside the hospital setting.

c.

making the client totally responsible for all physical care to improve confidence.

d.

role-playing potentially difficult social interactions with the client.

ANS: B, D

During the rehabilitation phase, appropriate outcomes for the diagnosis Disturbed Personal Identity revolve around the clients improving self esteem. Role-playing social situations and encouraging the client to interact with people outside the health care setting can all increase the clients confidence about social situations. Nurses should not down-play the appearance of the clients wounds; rather they need straightforward and factual information. Forcing the client to assume all physical cares might overwhelm the client.

DIF: Application/Applying REF: p. 1268 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Therapeutic Interactions

3. The older client is at greater risk of death following a burn because the older client (Select all that apply)

a.

does not have immunity to infections seen in burned clients.

b.

has a combination of age-related functional impairments.

c.

has thinner skin than a younger person does.

d.

may live alone without any social support.

ANS: B, C, D

Mortality after burns is higher in children younger than 4 and for adults over the age of 65. For the older client, this is due to a combination of age-related functional impairments (slower reaction time, impaired judgment, decreased mobility), living alone, environmental hazards, and significant preinjury morbidity. Thinning and atrophy of the skin compound the problem.

DIF: Knowledge/Remembering REF: pp. 1248-1249

OBJ: Assessment

MSC: Health Promotion and Maintenance Growth and Development Through the Lifespan-Age Related Differences

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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