Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:
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Solution
Limit the occurrence of drafts
Option C: A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas.
Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:
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Solution
Permeability of capillary walls
Option C: In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury?
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Solution
Impaired Adjustment
Option B: 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.
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?
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Solution
“My facial scars should be less severe with the use of this mask.”
Option D: The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. 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. The pressure garment will not change the angle of ear attachment to the head.
Which statement by the client indicates a correct understanding of rehabilitation after burn injury?
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Solution
“I will be fully recovered when I achieve the highest possible level of functioning that I can.”
Option D: 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.
What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures?
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Solution
“Because the graft is my own skin, there is no chance it won’t ‘take’.”
Option B: 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.
When should ambulation be initiated in the client who has sustained a major burn?
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Solution
As soon as possible after resolution of the fluid shift
Option D: 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.
Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?
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Solution
Changing gloves between wound care on different parts of the client’s body.
Option A: 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. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on difference parts of the client’s body can prevent autocontamination.
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?
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Solution
Notify the burn emergency team.
Option D: These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention.
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?
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Solution
Increased serum creatinine level
Option D: 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.