Which finding indicates to the nurse that the client understands the psychosocial impact of his severe burn injury?
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Solution
“It is normal to feel depressed.”
During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Feelings of grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.
Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance?
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Solution
Performing his own morning care
Indicators that the client with a burn injury has a positive perception of his appearance includes the willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications, but will not increase self-perception.
Which finding indicates that fluid resuscitation has been successful for a client with a burn injury?
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Solution
Urine output = 50 mL/hr
The fluid remobilization phase improves renal blood flow, increases diuresis, and restores blood pressure and heart rate to more normal levels, as well as laboratory values.
Which assessment finding assists the nurse in confirming inhalation injury?
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Solution
Brassy cough
Brassy cough and wheezing are some signs seen with inhalation injury. All the other symptoms are seen with carbon monoxide poisoning.
When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination?
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Solution
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. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination.
What statement indicates the client needs further education regarding the skin grafting (allografting)?
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Solution
“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 will work. The client should be prepared for the possibility that not all grafting procedures will be successful. The donor sites will be painful after the surgery, there can be scarring in the area where skin is removed for grafting, and the client is still at risk for infection.
What intervention will the nurse implement to reduce a client’s pain after a burn injury?
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Solution
Administering morphine 4 mg intravenously.
Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with
absorption from the muscle and stomach. Tactile stimulation can be used for pain management. For the client to avoid shivering, the room must be kept warm and heat should be applied.
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse’s best action?
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Solution
Documents the finding
Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this time.
Three days after a burn injury, the client develops a temperature of 100° F, white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition?
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Solution
Wound infection
Color change, purulent, foul-smelling drainage, increased white blood cell count, and fever could all indicate infection. These symptoms will not be seen in the acute phase of the injury. Autodigestion of collagen and granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge.
The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN?
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Solution
Wash hands on entering the client’s room.
Infection can occur when microorganisms from another person or the environment are transferred to the client. Although all the interventions listed can help reduce the risk for infection, hand washing is the most effective technique for preventing infection transmission.