Chapter 24: Burns Correctly Answered.

CHAPTER 24: BURNS CORRECTLY ANSWERED. The nurse recalls which description as the most accurate regarding a deep partial-thickness burn? - CORRECT ANSWER-painful with weeping blisters A deep partial-thickness burn involves the epidermal and dermal layers of the skin. Ir is characterized by a wet, shiny, weeping surface marked by blisters and is painful and very sensitive to the touch. Which assessment findings would alert the nurse to the presence of an inhalation injury in a burn patient? - CORRECT ANSWER-* singed nasal hair * increasing hoarseness * painful swallowing * history of being trapped in an enclosed space reliable clues to the occurrence of inhalation injury include the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being trapped in an enclosed space, altered mental status, and "cherry red' skin color What are the clinical manifestations of a lower airway lung injury associated with burns? - CORRECT ANSWER-*dyspnea *wheezing *altered mental status The nurse understands that which fluid and electrolyte change occurs during the early emergent phase of burn injury? - CORRECT ANSWER-movement of sodium and water into interstitial spaces After the burn, in the emergent phase, the capillary walls become more permeable, causing the movement of sodium, water, and plasma proteins into the interstitial spaces and surrounding tissues. What are the clinical manifestations of a upper airway lung injury associated with burns? - CORRECT ANSWER-edema and blisters Which clinical manifestation would the nurse anticpate due to thrombosis in the capillaries of the burned tissue of a patient? - CORRECT ANSWER-decreased erythrocyte count thrombosis in the capillaries of burned tissued results in a loss of circulating erthrocytes (red blood cells). Which type of burn injury would the nurse identify as occurring on the layers of subcutaneous fat, muscle, or deeper structures? - CORRECT ANSWER-full-thickness burn which clinical manifestation would the nurse observe in a patient during the emergent phase of a burn injury? - CORRECT ANSWER-*increased heart rate * decreased BP Which burn injury would the nurse identify as resulting in tissue anoxia? - CORRECT ANSWER-electrical injury Electrical injury causes tissue anoxia due to nerve damage and nerve death. The injury sustained by a thermal burn is dependent on the temperature of the burning agent and the length of exposure. Chemical burns can cause tissue damage and eyes can be injured if a splash occurs. Smoke and inhalational injury result in hypoxia. Which degree of burn would the nurse document for a patient with erythema, pain, and mild swelling following a burn injury? - CORRECT ANSWER-first A full-thickness scald injury is characterized by - CORRECT ANSWER-redness and edema at the affected site. It is caused by immersion of the body part in hot water