Preview Extract
Chapter 68
1. In order to determine the correct classification of a burn injury, it is essential to know:
Select all that apply.
1. The history of the event and location where the injury occurred.
2. The time the injury occurred.
3. The causative agent and the duration of exposure.
4. Any concurrent injuries.
5. Location of burns on the body.
Answer: 1. The history of the event and location where the injury occurred.
2. The time the injury occurred.
3. The causative agent and the duration of exposure.
4. Any concurrent injuries.
5. Location of burns on the body.
Rationale:
The history of the event and location where the injury occurred. If the injury occurred in an
enclosed area, such as a house, there also may be inhalation injuries that require special
consideration and treatment. The time the injury occurred. Fluid resuscitation calculations are
based on the time of the injury as opposed to the time of admission to the hospital. The
causative agent and the duration of exposure. The causative agent is especially important with
chemical burns such as from strong acids or alkaline agents, which may require neutralization
to stop the ongoing burning effect. Any concurrent injuries. Concurrent injuries, such as
fractures, often are associated with burns and require a treatment plan for stabilization.
Location of burns on the body. The location of the burns on the body is one of the important
determinates of classification. For example, burns of the face and hands are always
considered major burns.
2. The nurse is admitting a 25-year-old client to the emergency department with partialthickness injuries over 20% of the total body surface area, involving both lower legs. This
injury is classified as:
1. A moderate burn.
2. A minor burn.
3. A major.
4. A severe burn.
Answer: A moderate burn.
Rationale:
A minor burn is a partial-thickness injury that is less than 15% of total body surface area
(TBSA) in adults. A moderate injury is a partial-thickness injury that is between 15% and
25% of total body surface area in adults. The terms major and severe burn are used
interchangeably. They include all electrical injuries, inhalation injury, complicated injuries
(multiple trauma), high-risk clients such as older adults and those with chronic illnesses, and
all burns involving the ears, eyes, face, hands, feet, and perineum. A major burn also is a
partial-thickness injury that is greater than 25% of total body surface area in adults and fullthickness injuries 10% or greater.
3. The nurse is admitting a client who has sustained partial-thickness injury of 28% of total
body surface area (TBSA) and full-thickness injury of 30% or greater of TBSA. What is the
classification of this burn injury?
1. Major
2. Moderate
3. Minor
4. Superficial
Answer: Major
Rationale:
Partial-thickness injuries of greater than 25% of total body surface area in adults and fullthickness injuries 10% or greater of TBSA are considered major burns.
Partial-thickness injuries between 15% and 25% of total body surface area in adults and fullthickness injuries greater than 10% of TBSA not involving the ears, eyes, face, hands, feet,
and perineum are moderate injuries. Partial-thickness injuries of less than 15% of total body
surface area (TBSA) in adults and full-thickness injuries less than 2% of TBSA not involving
the ears, eyes, face, hands, feet, and perineum are considered minor injuries.
4. There has been a decline in burn injury deaths in the last two decades. The most significant
factor that impacted this decline is:
1. Early excision and closure of the burn wound.
2. Improved resuscitation.
3. Control of infection.
4. Support of the hypermetabolic response.
Answer: Early excision and closure of the burn wound.
Rationale:
The decline in the death rate from burn injuries is mostly attributed to early excision and
closure of the burn wound. Less significant reasons are improved resuscitation, control of
infection, and support of the hypermetabolic response.
5. The depth of a radiation injury occurring from an industrial accident at a nuclear power
plant depends on:
Select all that apply.
1. How close the individual was to the source.
2. The length of time of exposure to the source.
3. The temperature of the source.
4. The entry and exit sites on the body.
5. The amount of steam produced.
Answer: 1. How close the individual was to the source.
2. The length of time of exposure to the source.
Rationale:
How close the individual was to the source. The depth of a radiation injury depends on how
close the individual was to the source. The length of time of exposure to the source. The
depth of a radiation injury also depends on the length of time of exposure. The temperature of
the source. The temperature of the source is related to thermal and scald injuries. The entry
and exit sites on the body. Entry and exit wounds occur with electrical injuries. The amount
of steam produced. Steam is related to scald injuries.
6. Radiation burns can result from overexposure during radiation treatments for cancer.
Which cells are most susceptible to this type of radiation injury?
Select all that apply
1. Bone marrow
2. Skin
3. Gastrointestinal tract
4. Muscle
5. Kidney
Answer: 1. Bone marrow
2. Skin
3. Gastrointestinal tract
Rationale:
Bone marrow. The cells most susceptible to injury are those that divide rapidly, such as bone
marrow cells. Skin. The cells most susceptible to injury are those that divide rapidly, such as
skin cells. Gastrointestinal tract. The cells most susceptible to injury are those that divide
rapidly, such as calls of the gastrointestinal tract. Muscle. Muscle cells are not as susceptible
because they do not divide as rapidly as cells of the bone marrow, skin, and gastrointestinal
tract. Kidney. Cells of the kidney are not as susceptible because they do not divide as rapidly
as cells of the bone marrow, skin, and gastrointestinal tract.
7. In the outermost portion of the injured area, there is minor cell damage; this area is referred
to as the zone of hyperemia. What provides blood flow to the zone of hyperthermia?
1. Vasoactive mediators
2. Fibrinolysis mediators
3. Coagulation mediators
4. Tissue mediators
Answer: Vasoactive mediators
Rationale:
Due to the vasoactive mediators, there is prominent blood flow to the zone of hyperthermia.
Fibrinolysis mediators, coagulation mediators, and tissue mediators do not provide increased
blood flow to the zone of hyperthermia.
8. Which of the following laboratory results would not be expected in the first 24 hours after
a major burn injury?
Select all that apply.
1. Potassium level of 3.0 mEq/L
2. Hematocrit of 48%
3. Hemoglobin 19 g/dL
4. Sodium 148 mEq/L
Answer: Potassium level of 3.0 mEq/L
Rationale:
Cell damage, which occurs due to the burn injury, causes the release of intracellular
potassium, which causes hyperkalemia. Therefore, the potassium level is increased, not
decreased, in the first 24 hours. It is normal to have an elevated hematocrit, hemoglobin, and
sodium due to dehydration and hemoconcentration.
9. The nurse is admitting a 50-year-old female who was involved in a car accident whose
only injuries were burns over 50% of her body. Identify the highest-priority nursing diagnosis
for this client.
1. Deficient Fluid Volume
2. Acute Pain
3. Disturbed Body Image
4. Coping, family, compromised
Answer: Deficient Fluid Volume
Rationale:
Immediately after a burn injury, fluid begins to shift from the intracellular and intravascular
compartment into the interstitial space. This is commonly referred to as “third spacing” of
fluid and, if left untreated, will lead to hypovolemia and burn shock, which is life threatening.
Additionally, edema develops in unburned tissues and organs distant from the site of injury
when the burn size exceeds 20% of total body surface area. Acute Pain, Disturbed Body
Image, and Coping, family, compromised are all important nursing diagnoses, but are not as
critical as Deficient Fluid Volume at this time.
10. During the immediate postburn period, the nurse assesses the client for injuries other than
burns. Which of the following assessments indicates a potential problem?
1. Coughing
2. Urine output of 30 ml/hour
3. Presence of eschar
4. Presence of edema
Answer: Coughing
Rationale:
Coughing could indicate either an inhalation injury or a cold. Urine output of
30 ml/hour is a normal finding. The presence of eschar and edema are normal manifestations
of burn injuries.
11. During the acute phase of burn treatment, important goals of client care include:
Select all that apply.
1. Cleansing the wound.
2. Preventing loss of body heat through the wounds.
3. Providing for client comfort.
4. Preventing infection.
5. Providing adequate nutrition for healing to occur.
6. Splinting, positioning, and exercising affected joints.
Answer: 1. Cleansing the wound.
2. Preventing loss of body heat through the wounds.
3. Providing for client comfort.
4. Preventing infection.
5. Providing adequate nutrition for healing to occur.
6. Splinting, positioning, and exercising affected joints.
Rationale:
Cleansing the wound. The goals of treatment for the acute period include wound cleansing
and healing. Preventing loss of body heat through the wounds. The goals of treatment for the
acute period include preserving body heat. Providing for client comfort. The goals of
treatment for the acute period include pain relief. Preventing infection. The goals of treatment
for the acute period include preventing infection. Providing adequate nutrition for healing to
occur. The goals of treatment for the acute period include promoting nutrition. Splinting,
positioning, and exercising affected joints. The goals of treatment for the acute period include
splinting, positioning, and exercising affected joints.
12. During the acute period of burn care, the focus of care is to promote healing of fullthickness burn wounds. In order for this to occur, the wound must:
1. Be free of eschar.
2. Have decreased tissue perfusion.
3. Have the edema decreased with diuretics.
4. Be pain free.
Answer: Be free of eschar.
Rationale:
In order for the wound to heal, it must be free of the dead tissue that is a result of burn injury.
In order for a burn to heal it needs increased tissue perfusion to get the nutrients needed for
the healing process. Diuretics are not used to decease the edema. The client will not be pain
free until the wound is completely closed.
13. The mortality rate for burns is highest in the very young and in the elderly population.
What factors put the very young at a higher risk?
Select all that apply.
1. Infants and young children have an immature immune system with a weak antibody
response.
2. The very young have a greater proportion of body surface area per amount of body mass,
resulting in a higher risk for fluid-volume loss.
3. The very young have an increased risk for the development of hypovolemic shock.
4. In the very young, burns tend to exacerbate previous medical problems.
5. The very young tend to heal more slowly.
Answer: 1. Infants and young children have an immature immune system with a weak
antibody response.
2. The very young have a greater proportion of body surface area per amount of body mass,
resulting in a higher risk for fluid-volume loss.
3. The very young have an increased risk for the development of hypovolemic shock.
Rationale:
Infants and young children have an immature immune system with a weak antibody response.
Infants and young children have an immature immune system with a weak antibody response
to infection and tend to die of septicemia. The very young have a greater proportion of body
surface area per amount of body mass, resulting in a higher risk for fluid-volume loss. The
very young have greater proportion of body surface area per amount of body mass, and as a
result there is a higher risk for fluid-volume loss as compared to adults. The very young have
an increased risk for the development of hypovolemic shock. As a result of a higher risk for
fluid-volume loss, there is an increased risk for the development of hypovolemic shock. In
the very young, burns tend to exacerbate previous medical problems. This is true of the
elderly, not the very young. The very young tend to heal more slowly. This is true of the
elderly, not the very young.
14. What factors decrease the rate of survival of burn injuries?
Select all that apply.
1. Cardiac disease
2. Renal disease
3. Endocrine diseases
4. History of substance abuse
5. Age
Answer: 1. Cardiac disease
2. Renal disease
3. Endocrine diseases
4. History of substance abuse
5. Age
Rationale:
Cardiac and respiratory diseases. Previous cardiac disease increases the mortality rate
because the added insult of burn injury is overwhelming. Stimulation of the sympathetic
nervous system causes the release of catecholamines (epinephrine and norepinephrine),
increases systemic vascular resistance, and thus increases cardiac workload. Renal disease.
The hypovolemia that occurs as a result of fluid shifts causes a decrease in renal blood flow
and filtration rates, which increases the risk for renal failure. There is a higher risk for renal
failure when any of the following is also present: dehydration, acidosis, massive presence of
necrotic tissue after third- and fourth-degree electrical and chemical burns, hypercatabolic
state, and/or shock. Renal failure increases the mortality rate of burn injuries. Endocrine
diseases. In the presence of endocrine abnormalities such as diabetes, the added insult of a
burn injury exacerbates the disease and impacts wound healing and the immune response.
These patients tend to die from overwhelming infection. History of substance abuse.
Preinjury status is a major factor in an individual’s ability to survive a burn injury. Age. The
very young and the elderly have higher mortality rates than a young adult with the same
percentage of burn injury. In the younger population (usually under 2 years of age), there are
two specific reasons for increased mortality. First, infants and young children have an
immature immune system with a weak antibody response to infection and tend to die of
septicemia. Second, the very young have a greater proportion of body surface area per
amount of body mass. As a result, there is a higher risk for fluid-volume loss, requiring
greater fluid resuscitation for total percent burn as compared to adults. Therefore, there is an
increased risk for the development of hypovolemic shock. In the older population (over 60
years of age), burns tend to exacerbate previous medical problems such as cardiovascular
disease, renal insufficiency, diabetes, and chronic obstructive pulmonary disease. This
population tends to have decreased physiological reserves, which are needed to respond to the
stress of a burn injury; therefore, older adults are at a higher risk for shock and multisystem
organ failure. Additionally, the older population tends to heal more slowly, resulting in a
greater risk for the development of infection and pneumonia.
15. Escharotomies were performed on the arms of a client because of circumferential burn
injuries. The nurse's first priority assessment would be to assess the arms for:
1. Circulation in the extremity distal to the escharotomy.
2. Wound infection in the escharotomy site.
3. The extent of the client’s ability to perform range-of-motion exercises.
4. The contracture formation.
Answer: Circulation in the extremity distal to the escharotomy.
Rationale:
Frequent monitoring of the circulation distal to the escharotomy site is part of the ongoing
nursing assessment and includes pulses, tissue color including paleness and cyanosis,
sensation, increased pain, capillary refill, and decreased temperature. Often it is necessary to
monitor circulation every 15 to 20 minutes. Wound infection would not occur immediately;
therefore is not the first priority. Range of motion decreases as the wounds heal, not
immediately. Contracture formation occurs later, as the wounds heal.
16. The purpose of meshing the donor skin for grafting is to:
1. Increase the size of the graft.
2. Improve the cosmetic effect.
3. Increase the rejection rate of the graft.
4. Increase the thickness of the graft.
Answer: Increase the size of the graft.
Rationale:
Meshing a graft means cutting holes in the harvested skin, which allows it to be stretched
over a greater surface area. The meshed skin graft can be increased from two to nine times its
original size, depending on the size of the holes. Meshed skin grafts heal with the diamond
pattern remaining for the rest of the client’s life, and therefore they are not as cosmetically
pleasing as sheet grafts. Mesh grafts have a decreased rejection rate. Meshing the graft does
not increase the thickness of the graft.
17. After the dressing change, the client needs to be positioned in bed. Which of the
following measures would be inappropriate nursing care for reducing contractures?
1. Placing a pillow under the knee of a client with burns on the posterior legs.
2. Splinting the affected extremity in a functional position.
3. Daily physical therapy and range-of-motion exercises.
4. Hyperextending the neck of a client with burns of the anterior chest and neck.
Answer: Placing a pillow under the knee of a client with burns on the posterior legs.
Rationale:
The correct position for the legs is to be hyperextended. Placing a pillow under the legs
would promote contracture formation. Splinting and daily physical therapy are indicated for
preventing contracture formation. Hyperextending the neck of a client with burns of the
anterior chest and neck will help decrease contracture formation.
18. When caring for a burn client, the nurse knows that nutrition is essential for burn wounds
to heal. Which of the following nutrition plans would be ideal to increase wound healing?
1. A daily balanced diet, high in calories and protein, additional 1.5-calorie/cc liquid
supplements, and vitamin replacement
2. A daily balanced diet that is high in calories and protein
3. A daily balanced diet, high in protein, and additional 1.5-calorie/cc liquid supplements
4. A daily balanced diet, high in calories, additional 1.5-calorie/cc liquid supplements, and
vitamin replacement
Answer: A daily balanced diet, high in calories and protein, additional 1.5-calorie/cc liquid
supplements, and vitamin replacement
Rationale:
The diet must be high in calories and protein. Typically, food alone does not supply the
needed calories; therefore, supplementing with high-calorie drinks and vitamins is necessary.
Food alone, high-calorie drinks alone, and vitamins alone will not provide adequate nutrients
19. The nurse is preparing a client for discharge from the hospital following a major burn
injury. The nurse is developing a plan for his nutrition and understands that:
1. The hypermetabolic state continues until all the wounds are healed.
2. The hypermetabolic state is only present in the emergency and acute periods of burn care.
3. No extra calories are necessary once discharged from the hospital.
4. The calorie intake should be decreased so as not to gain weight.
Answer: The hypermetabolic state continues until all the wounds are healed.
Rationale:
The hypermetabolic state continues until the burn wounds are completely healed, which can
take up to 12 to 18 months after the injury. Therefore, it is essential that the client continue
with increased calorie and vitamin intake after discharge from the hospital. Decreasing
calorie intake is inappropriate.
20. List the factors that affect the grief reaction to a burn injury that a client faces on
discharge from the hospital.
Select all that apply.
1. Body image change
2. Loss of physical functioning
3. Potential change in vocation
4. Separation from home and family
5. Change in family role patterns
Answer: 1. Body image change
2. Loss of physical functioning
3. Potential change in vocation
4. Separation from home and family
5. Change in family role patterns
Rationale:
Body image change. The change in body image is the primary reason for the grief response.
Loss of physical functioning. Loss of psychical functioning impacts many aspects of the grief
reaction, such as change in vocation and change in family role patters. Potential change in
vocation. This is included in the grief response because it poses a threat to financial
independence. Separation from home and family. Recovering from a major burn injury
necessitates a prolonged hospitalization. This means separation form loved ones, which
causes grief. Change in family role patterns. A shift in family role patterns, especially the
bread-winner role, upsets family structure and is a factor in the grief process.
21. The nurse is teaching a burn client about the need for continued stretching exercises after
discharge from the hospital. The nurse knows that the client understands what is necessary
when he states:
1. “Stretching exercises are used to elongate shortened soft tissue and increase range of
motion.”
2. “A progressive exercise program will not increase my overall stamina.”
3. “Blanching of the scar means I have stretched too far.”
4. “If I stretch, I don’t need to use my splints.”
Answer: “Stretching exercises are used to elongate shortened soft tissue and increase range of
motion.”
Rationale:
Stretching can be a passive or an active activity, and clients must learn to perform selfstretching exercises as they prepare for discharge. The stretch should be gentle, slow, and
sustained. Blanching of the scar represents appropriate stretch. Immediately after a stretching
session, positioning and splinting are used effectively to maintain the elongation of the tissue.
22. What factor would put the client at a risk for converting a partial-thickness injury to a
full-thickness injury?
1. Wound infection
2. Fluid overload
3. Kidney disease
4. Pneumonia
Answer: Wound infection
Rationale:
Infection, trauma, and a decreased blood supply increase the risk of a partial-thickness injury
converting to a full-thickness injury. Fluid overload, kidney disease, and pneumonia are not
specifically related to converting a partial-thickness injury to a full-thickness injury.
23. When the nurse is attempting to manipulate the burn client's environment to diminish
stress in order to promote wound healing, which of the following is not appropriate for a burn
client?
1. Keeping the room cool
2. Pain medication
3. Closing the curtains
4. Noise control
Answer: Keeping the room cool
Rationale:
Burn clients have ineffective thermoregulation related to epithelial skin loss. Therefore, heat
shields, warm blankets, and increased room temperature are methods used to help maintain
body temperature. Therefore, keeping the room cool is inappropriate. Pain control, noise
control, and closing the curtains would all be therapeutic for a burn client.
24. Which complication of burn injuries is common to all three periods of burn management
for a client with a major injury?
1. Psychological problems
2. Wound infection
3. Contractures
4. Stress ulcers
Answer: Psychological problems
Rationale:
Psychological problems span all three periods of burn recovery. The problems begin with the
initial realization of the critical nature of the injury in the emergency period to the final
realization of the permanent scarring. Wound infection occurs primarily in the acute period.
Contractures occur in the rehabilitative period, and stress ulcers occur primarily in the
emergency period.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
