A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (Select all that apply.)
Submerge client in a cold bath
Administer oxygen
Restrict fluids
Provide a meal high in fiber
Assess airway
Apply ice to burned areas
Correct Answer : E,F
Choice A Reason: This is incorrect because submerging the client in a cold bath can cause hypothermia, shock, or infection. Cold water can lower the body temperature and blood pressure, which can impair circulation and organ function. Cold water can also introduce bacteria or contaminants into the open wounds. The nurse should use cool water or saline to gently irrigate the burned areas and then cover them with sterile dressings.
Choice B Reason: This is correct because administering oxygen can help the client breathe better and prevent hypoxia. Burns to the face, neck, or chest can cause swelling or damage to the airway, which can impair gas exchange and oxygen delivery. Oxygen can also reduce the risk of carbon monoxide poisoning, which can occur from inhaling smoke or fumes.
Choice C Reason: This is incorrect because restricting fluids can worsen dehydration and shock. Burns can cause significant fluid and electrolyte loss through evaporation and leakage from damaged capillaries. This can lead to hypovolemia, which is low blood volume, and hypotension, which is low blood pressure. The nurse should monitor the client's vital signs, urine output, and weight, and administer intravenous fluids as ordered.
Choice D Reason: This is incorrect because providing a meal high in fiber can cause abdominal discomfort or diarrhea. Burns can cause paralytic ileus, which is a temporary loss of bowel function due to nerve damage or inflammation. This can impair digestion and absorption of food and cause nausea, vomiting, or constipation. The nurse should assess the client's bowel sounds and provide enteral or parenteral nutrition as ordered.
Choice E Reason: This is correct because assessing airway is a priority nursing action for a client with burns. As mentioned above, burns to the face, neck, or chest can compromise the airway and cause respiratory distress or failure. The nurse should assess the client's level of consciousness, breathing rate and pattern, oxygen saturation, and signs of inhalation injury, such as sooty sputum, singed nasal hairs, or hoarseness. The nurse should also be prepared to assist with intubation or tracheostomy if needed.
Choice F Reason: This is correct because applying ice to burned areas can help reduce pain and swelling. Ice can constrict blood vessels and numb nerve endings, which can decrease inflammation and sensation. However, ice should be applied for no more than 15 minutes at a time and wrapped in a cloth or towel to prevent frostbite or tissue damage. Ice should not be applied to large or deep burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because this question will help the nurse assess the pain level and discomfort of the client with red scaling papules. Red scaling papules are raised skin lesions that are red and covered with scales. They can indicate psoriasis, which is a chronic skin condition that causes inflammation and rapid turnover of skin cells. Psoriasis can cause pain, itching, burning, or stinging sensations in the affected areas. The nurse should ask the client to rate their pain on a numeric or descriptive scale and provide analgesics or topical agents as prescribed.
Choice B reason: This is incorrect because this question will not help the nurse assess the condition of the client with red scaling papules. Red scaling papules are not affected by food intake but by other factors such as stress, infection, injury, or medication. Psoriasis is not an allergic or dietary disorder, but an immune-mediated disorder that causes abnormal skin cell growth. The nurse should ask the client about their medical history, current medications, and triggers or aggravating factors for their psoriasis.
Choice C reason: This is incorrect because this question will not help the nurse assess the condition of the client with red scaling papules. Red scaling papules are not treated with antibiotics but with other medications such as corticosteroids, immunosuppressants, or biologics. Antibiotics are used to treat bacterial infections, which are not the cause of psoriasis. The nurse should ask the client about their treatment regimen, compliance, and effectiveness for their psoriasis.
Choice D reason: This is incorrect because this question will not help the nurse assess the condition of
the client with red scaling papules. Red scaling papules are not related to weekend activities but to chronic skin inflammation and abnormal cell turnover. Psoriasis is not a lifestyle disorder, but a genetic disorder that can be influenced by environmental factors. The nurse should ask the client about their family history, exposure to sun or cold, and stress level for their psoriasis.
Correct Answer is ["B","D","E"]
Explanation
The correct answers are b, d, and e.
Choice A: Slurred speech.
Slurred speech can be associated with increased ICP due to the pressure effects on the brain areas responsible for speech production. However, it is not typically considered a late sign of increased ICP. It may occur earlier in the progression as the brain's ability to coordinate muscle movements is affected.
Choice B: Bradycardia with a bounding pulse.
Bradycardia with a bounding pulse is a classic sign of Cushing's triad, which is a late and ominous sign of significantly increased ICP. It indicates that the body is attempting to increase arterial blood pressure to overcome the increased ICP and maintain cerebral perfusion. The normal range for adult heart rate is 60-100 beats per minute.
Choice C: Confusion.
Confusion can be an early sign of increased ICP as it can indicate changes in cerebral function. However, it is not specifically a late sign of increased ICP. Early signs of increased ICP can include headache, nausea, and confusion, as the brain is initially responding to the pressure changes.
Choice D: Hypertension with an increasing pulse pressure.
Hypertension with an increasing pulse pressure is another component of Cushing's triad. It reflects the body's compensatory mechanism to preserve cerebral blood flow in the face of rising ICP. An increasing pulse pressure (the difference between systolic and diastolic blood pressure) is a late sign of increased ICP. Normal pulse pressure is typically 30-40 mm Hg.
Choice E: Nonreactive dilated pupils.
Nonreactive dilated pupils are a late sign of increased ICP and indicate pressure on the cranial nerves that control pupil size and reaction to light. This is a grave sign and often indicates impending brain herniation.
Choice F: Hypotension with a decreasing pulse pressure.
Hypotension with a decreasing pulse pressure is not typically associated with increased ICP. In fact, hypertension with a widening pulse pressure would be more indicative of increased ICP as part of Cushing's triad.
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