NUR 265 Advanced Concepts of
Medical–Surgical Nursing
Exam 3
Question:
Which finding indicates to the nurse that a client with a burn injury has a
positive perception of his appearance?
Answer:
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
Question:
Which finding indicates to the nurse that the client understands the
psychosocial impact of his severe burn injury?
Answer:
It is normal to feel depressed.
,Question:
Which finding is characteristic during the emergent period after a deep full
thickness burn injury?
Answer:
Urine output of 10ml/hr
During the fluid shift of the emergent period, blood flow to the kidney may
not be adequate for glomerular filtration. As a result, urine output is greatly
decreased. Foul-smelling discharge does not occur during the emergent
phase and blood pressure is usually low. Pain does not occur with deep full-
thickness burns.
Question:
Which is the priority nursing diagnosis during the first 24 hours for a client
with chemical burns to the legs and arms that are red in color, edematous,
and without pain?
Answer:
Decreased tissue perfusion
During the emergent phase, fluid shifts into interstitial tissue in burned
areas. When the burn is circumferential on an extremity, the swelling can
compress blood vessels to such an extent that circulation is impaired distal
to the injury, causing decreased tissue perfusion and necessitating the
intervention of an escharotomy. Chemical burns do not cause inhalation
injury and a disrupted breathing pattern. Disturbed body image and disuse
syndrome can develop. However, these are not priority diagnoses at this
time.
,Question:
Which laboratory result, obtained on a client 24 hours post-burn injury, will
the nurse report to the physician immediately?
Answer:
Serum potassium,7.5 mmol/L (mEq/L)
Question:
Which nursing intervention is likely to be most helpful in providing
adequate nutrition while the client is recovering from a thermal burn injury?
Answer:
Allowing the client to eat whenever he or she wants
Clients should request food whenever they think that they can eat, not just
according to the hospital's standard meal schedule. The nurse needs to work
with a nutritionist to provide a high-calorie, high-protein diet to help with
wound healing. Clients who can eat solid foods should ingest as many
calories as possible. Parenteral nutrition may be given as a last resort
because it is invasive and can lead to infectious and metabolic complications.
Question:
Which statement best exemplifies the client's understanding of
rehabilitation after a full-thickness burn injury?
Answer:
"My goal is to achieve the highest level of functioning that I can"
, Question:
Which statement indicates that a client with facial burns understands the
need to wear a facial pressure garment?
Answer:
"My facial scars will be less with the use of this facial mask"
Question:
he client with a dressing covering the neck is experiencing some respiratory
difficulty. What is the nurse's best first action
Answer:
Loosen the dressing
Question:
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?
Answer:
Increased serum creatinine levels.
Medical–Surgical Nursing
Exam 3
Question:
Which finding indicates to the nurse that a client with a burn injury has a
positive perception of his appearance?
Answer:
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
Question:
Which finding indicates to the nurse that the client understands the
psychosocial impact of his severe burn injury?
Answer:
It is normal to feel depressed.
,Question:
Which finding is characteristic during the emergent period after a deep full
thickness burn injury?
Answer:
Urine output of 10ml/hr
During the fluid shift of the emergent period, blood flow to the kidney may
not be adequate for glomerular filtration. As a result, urine output is greatly
decreased. Foul-smelling discharge does not occur during the emergent
phase and blood pressure is usually low. Pain does not occur with deep full-
thickness burns.
Question:
Which is the priority nursing diagnosis during the first 24 hours for a client
with chemical burns to the legs and arms that are red in color, edematous,
and without pain?
Answer:
Decreased tissue perfusion
During the emergent phase, fluid shifts into interstitial tissue in burned
areas. When the burn is circumferential on an extremity, the swelling can
compress blood vessels to such an extent that circulation is impaired distal
to the injury, causing decreased tissue perfusion and necessitating the
intervention of an escharotomy. Chemical burns do not cause inhalation
injury and a disrupted breathing pattern. Disturbed body image and disuse
syndrome can develop. However, these are not priority diagnoses at this
time.
,Question:
Which laboratory result, obtained on a client 24 hours post-burn injury, will
the nurse report to the physician immediately?
Answer:
Serum potassium,7.5 mmol/L (mEq/L)
Question:
Which nursing intervention is likely to be most helpful in providing
adequate nutrition while the client is recovering from a thermal burn injury?
Answer:
Allowing the client to eat whenever he or she wants
Clients should request food whenever they think that they can eat, not just
according to the hospital's standard meal schedule. The nurse needs to work
with a nutritionist to provide a high-calorie, high-protein diet to help with
wound healing. Clients who can eat solid foods should ingest as many
calories as possible. Parenteral nutrition may be given as a last resort
because it is invasive and can lead to infectious and metabolic complications.
Question:
Which statement best exemplifies the client's understanding of
rehabilitation after a full-thickness burn injury?
Answer:
"My goal is to achieve the highest level of functioning that I can"
, Question:
Which statement indicates that a client with facial burns understands the
need to wear a facial pressure garment?
Answer:
"My facial scars will be less with the use of this facial mask"
Question:
he client with a dressing covering the neck is experiencing some respiratory
difficulty. What is the nurse's best first action
Answer:
Loosen the dressing
Question:
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?
Answer:
Increased serum creatinine levels.
