Medical-Surgical Nursing ii Perspectives and Assessment of Care Practice Questions

1. Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? a. Deep partial thickness i. Rationale: a deep partial thickness burn involves destruction of the epidermis and upper layers of the dermis as well as injury to deeper portions of the dermis as well as injury to deeper portions of the dermis 2. The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? a. Contact the primary care provider and prepare for an escharotomy. i. Rationale: the nurse assesses peripheral pulses frequently with a doppler ultrasound device if needed, frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity, it is necessary for the nurse to report loss od pulse or sensation or presence of pain to the physician immediately and to prepare to assist with escharotomy 3. Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? a. Roll the client in a blanket i. Rationale: at the scene of a fire, the client should be rolled in a blanket to smother the fire, the client should be placed in a horizontal position to precent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage 4. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to a. Decease catabolism i. Rationale: the most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50% 5. Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? a. Mechanical i. Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar 6. Which zone of burn injury sustains the most damage? a. Inner i. Each burned area has three zones of injury, inner area (known as the zone of coagulation, where cellular death occurs) sustains the most damage 7. The nurse recognize what as an early sign of sepsis in a client with a burn injury? a. Elevated serum glucose i. Rationale: in clients with burn injuries early sepsis can be hard to detect, clients with burn injuries exhibit tachycardia, tachypnea, and elevated body temperature, all typical indications of sepsis, In the client with burn injury, indications of sepsis include elevated serum glucose values, increased heart rate, and narrowing mean arterial pressure 8. The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? a. Music therapy may provide reality orientation, distraction, and sensory stimulation i. Rationale: researchers have found that music affects both the physiologic and psychological aspects of the pain experience, music diverts the clients attention away from the painful stimulus, music may also provide reality orientation, distraction, and sensory stimulation 9. The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply. a. Participates actively in daily activities b. Wears hats and wigs i. Rationale: The following are indicators that a client is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. 10. A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply. a. This medication will be applied directly to the wound b. This medication is an antibacterial c. This medication will help my burn heal i. Rationale: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound as it will help heal the client’s burned areas