ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 66 : Caring for Clients With Burns Questions
Question 1 of 5
A client is brought to the emergency department with burns in irregular shapes scattered over multiple areas of the body. Which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn?
Correct Answer: B
Rationale: A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client's palm size to approximate the total body surface. The palm is approximately 1% of a person's TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Broweder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of times quantitates burns that involve entire sections of the body, not scattered burns.
Question 2 of 5
During the recovery of an extensive burn, the client is complaining about wearing the tight-fitting custom garment. What is an appropriate response by the nurse?
Correct Answer: C
Rationale: The forming of burn scars can be minimized by the use of pressure dressings and custom-fitted garments that apply continuous pressure. Garments need to be snug in order to be effective. These garments are worn for 23 hours a day and may be prescribed for as long as 2 years. Prevention of infection is not indicated with use.
Question 3 of 5
The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?
Correct Answer: C
Rationale: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.
Question 4 of 5
A client is brought to the emergency department after sustaining a serious burn. The nurse understands that the focused management of which burn zone is of greatest concern?
Correct Answer: D
Rationale: The zone of stasis lies outside the burn center and zone of coagulation. This is where the blood vessels are damaged, but tissue has the potential to survive with proper management. The center zone or zone of coagulation is the deepest area of injury and is considered the zone of irreversible damage, placing the focus on saving the surrounding tissues. The zone of hyperemia is the area of least injury.
Question 5 of 5
An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?
Correct Answer: B
Rationale: In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opoids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.