Exam 1 Questions 66-100 ACTUAL UPDATED QUESTIONS AND CORRECT
ANSWERS
A client who was burned in a workplace accident has Correct response:
completed the acute phase of treatment and the plan of Providing education to the client and family
care has been altered to prioritize rehabilitation. What
nursing action should be prioritized during this phase of Explanation:
treatment? Client and family education is a priority during rehabilitation. There should be no
fluid and electrolyte imbalances in the rehabilitation phase. The presence of
impaired thermoregulation or infection would suggest that the client is still in the
acute phase of burn recovery.
A client with a burn injury is in acute stress. Which of the Correct response:
following complications is prone to develop in this client? Gastric ulcers
Explanation:
The release of histamine as a consequence of the stress response increases
gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers.
Anemia develops because of the heat destroying the erythrocytes. Release of
histamine does not cause hyperthyroidism or cardiac arrest.
Which of the following is a disadvantage of surgical Correct response:
debridement? Bleeding
Explanation:
A disadvantage of surgical debridement is bleeding. Scarring, loss of function,
and contractures are not disadvantages of surgical debridement.
Which of the following clients with burns is more prone Correct response:
to infection and requires close monitoring by the nurse? A client with burns in the perineal area
Explanation:
The nurse should closely monitor for infection from organisms in the stool in a
client with burns in the perineal area because the area is susceptible to bacterial
colonization. Burns of the face, neck, or chest have the potential to impair
ventilation, while those involving the hands, legs, abdominal area, or major joints
may affect dexterity and mobility.
A client receiving emergency treatment for severe burns Correct response:
has just been assessed to establish the burn depth. Why The early appearance of the burn injury may change.
is a nurse asked to reassess the burn depth after 72
hours? Explanation:
The nurse is required to reassess and revise the estimate of burn depth because
the early appearance of the burn injury may change. Assessing the burn depth
helps determine the potential of the damaged tissue to survive. It does not
establish the percentage of the TBSA that is burned or minimize the risk of
infections. It also does not help determine whether the client's condition is likely
to deteriorate after 72 hours.
, Which of the following types of shock will a nurse Correct response:
observe in a client with extensive burns? Hypovolemic shock
Explanation:
Clients with extensive burns may exhibit hypovolemic shock due to the loss of
blood or plasma. Clients with extensive burns are unlikely to display the symptoms
of anaphylactic, neurogenic, or septic shock.
Which of the following is the effect of protein catabolism Correct response:
in a client with severe burns? It compromises wound healing and immunocompetence.
Explanation:
Protein catabolism in a client with severe burns compromises wound healing and
immunocompetence. Burns of the face, neck, or chest have the potential to impair
ventilation, while burns involving the hands or major joints may affect dexterity
and mobility. Release of aldosterone, not protein catabolism, causes sodium
retention.
Which type of graft utilizes the client's own skin for Correct response:
wound coverage? Autograft
Explanation:
An autograft uses the client's own skin, which is transplanted from one part of the
body to another. A heterograft is obtained from animals, principally pigs. An
allograft is human skin obtained from a cadaver. A slit graft is used when the area
available as a donor site is limited, as in clients with extensive burns.
Which type of skin graft is more comparable in Correct response:
appearance to normal skin? Full-thickness graft
Explanation:
Full-thickness grafts are more comparable in appearance to normal skin and can
tolerate more stress once they become permanently attached to the burn wound.
A slit graft (lace graft) is used when the area available as a donor site is limited, as
in clients with extensive burns. In a split thickness graft, the epidermis and a thin
layer of the dermis are harvested from the client's skin.
Which of the following is a true statement regarding the Correct response:
purposes of skin grafts? Reduces scarring and contractures.
Explanation:
Purposes of a skin graft include the reduction of scarring and contractures, to
decrease evaporative fluid loss, decrease the potential for infection, and speed
recovery.
Which type of burn is similar to a sunburn? Correct response:
Superficial partial-thickness
Explanation:
A superficial partial-thickness burn is similar to a sunburn. Deep partial thickness
burns may need debridement and may scar. Full-thickness burns destroy all layers
of the skin and consequently are painless. Electrical burns are a type of burn but
not a category of burn thickness.
ANSWERS
A client who was burned in a workplace accident has Correct response:
completed the acute phase of treatment and the plan of Providing education to the client and family
care has been altered to prioritize rehabilitation. What
nursing action should be prioritized during this phase of Explanation:
treatment? Client and family education is a priority during rehabilitation. There should be no
fluid and electrolyte imbalances in the rehabilitation phase. The presence of
impaired thermoregulation or infection would suggest that the client is still in the
acute phase of burn recovery.
A client with a burn injury is in acute stress. Which of the Correct response:
following complications is prone to develop in this client? Gastric ulcers
Explanation:
The release of histamine as a consequence of the stress response increases
gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers.
Anemia develops because of the heat destroying the erythrocytes. Release of
histamine does not cause hyperthyroidism or cardiac arrest.
Which of the following is a disadvantage of surgical Correct response:
debridement? Bleeding
Explanation:
A disadvantage of surgical debridement is bleeding. Scarring, loss of function,
and contractures are not disadvantages of surgical debridement.
Which of the following clients with burns is more prone Correct response:
to infection and requires close monitoring by the nurse? A client with burns in the perineal area
Explanation:
The nurse should closely monitor for infection from organisms in the stool in a
client with burns in the perineal area because the area is susceptible to bacterial
colonization. Burns of the face, neck, or chest have the potential to impair
ventilation, while those involving the hands, legs, abdominal area, or major joints
may affect dexterity and mobility.
A client receiving emergency treatment for severe burns Correct response:
has just been assessed to establish the burn depth. Why The early appearance of the burn injury may change.
is a nurse asked to reassess the burn depth after 72
hours? Explanation:
The nurse is required to reassess and revise the estimate of burn depth because
the early appearance of the burn injury may change. Assessing the burn depth
helps determine the potential of the damaged tissue to survive. It does not
establish the percentage of the TBSA that is burned or minimize the risk of
infections. It also does not help determine whether the client's condition is likely
to deteriorate after 72 hours.
, Which of the following types of shock will a nurse Correct response:
observe in a client with extensive burns? Hypovolemic shock
Explanation:
Clients with extensive burns may exhibit hypovolemic shock due to the loss of
blood or plasma. Clients with extensive burns are unlikely to display the symptoms
of anaphylactic, neurogenic, or septic shock.
Which of the following is the effect of protein catabolism Correct response:
in a client with severe burns? It compromises wound healing and immunocompetence.
Explanation:
Protein catabolism in a client with severe burns compromises wound healing and
immunocompetence. Burns of the face, neck, or chest have the potential to impair
ventilation, while burns involving the hands or major joints may affect dexterity
and mobility. Release of aldosterone, not protein catabolism, causes sodium
retention.
Which type of graft utilizes the client's own skin for Correct response:
wound coverage? Autograft
Explanation:
An autograft uses the client's own skin, which is transplanted from one part of the
body to another. A heterograft is obtained from animals, principally pigs. An
allograft is human skin obtained from a cadaver. A slit graft is used when the area
available as a donor site is limited, as in clients with extensive burns.
Which type of skin graft is more comparable in Correct response:
appearance to normal skin? Full-thickness graft
Explanation:
Full-thickness grafts are more comparable in appearance to normal skin and can
tolerate more stress once they become permanently attached to the burn wound.
A slit graft (lace graft) is used when the area available as a donor site is limited, as
in clients with extensive burns. In a split thickness graft, the epidermis and a thin
layer of the dermis are harvested from the client's skin.
Which of the following is a true statement regarding the Correct response:
purposes of skin grafts? Reduces scarring and contractures.
Explanation:
Purposes of a skin graft include the reduction of scarring and contractures, to
decrease evaporative fluid loss, decrease the potential for infection, and speed
recovery.
Which type of burn is similar to a sunburn? Correct response:
Superficial partial-thickness
Explanation:
A superficial partial-thickness burn is similar to a sunburn. Deep partial thickness
burns may need debridement and may scar. Full-thickness burns destroy all layers
of the skin and consequently are painless. Electrical burns are a type of burn but
not a category of burn thickness.
