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A nurse is assessing a client who has an electrical burn. Which of the following cues should the nurse recognize as indicating a potential complication of the burn injury?

Cool and clammy skin

Purulent drainage from the burn site

Muscle weakness

Irregular heart rhythm

Answer and Explanation

The Correct Answer is D

A. Cool and clammy skin:
May indicate shock but is not specific to electrical burns.

B. Purulent drainage from the burn site:
Suggests infection, a later complication rather than immediate concern.

C. Muscle weakness:
Can occur but is less urgent than cardiac effects.

D. Irregular heart rhythm:
Electrical burns can cause internal cardiac damage and arrhythmias-potentially life-threatening.

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Correct Answer is ["B","C","E"]

Explanation

A. Fluid volume deficit: This is an acute phase complication. After 12 months, the client is in the rehabilitation phase, and fluid balance is typically stabilized.

B. Symptoms of post-traumatic stress: PTSD is common after severe burn trauma, especially with long hospital stays or painful treatments.

C. Depression: Chronic physical and emotional stress, changes in appearance, and functional limitations contribute to depression.

D. Electrolyte imbalances: These are more likely during the acute and early recovery phase. At 12 months, electrolyte levels are usually normalized unless other complications exist.

E. Body image disorder: Disfigurement and scarring from severe burns often result in body image disturbances, which affect emotional well-being and social reintegration.

Correct Answer is []

Explanation

Potential Condition: Urinary Tract Infection (UTI)
The client is reporting frequency, burning, and urgency, classic symptoms of a lower UTI (cystitis). The recent removal of the urinary catheter (which increases infection risk) further supports this.

Actions to take:

Check a urine culture and sensitivity: A urine culture will confirm the presence of infection and identify the specific organism, allowing for appropriate antibiotic selection.
Request a prescription for an antispasmodic agent: Bladder spasms can contribute to frequency and urgency, especially post-catheter removal. An antispasmodic (e.g., oxybutynin) may help relieve discomfort.

Parameters to monitor:

Temperature: Fever can indicate progression of the UTI to pyelonephritis or worsening infection. The current low-grade fever of 100.4°F may be an early sign.
Fluid intake: Adequate hydration helps flush bacteria from the urinary tract and is essential in promoting recovery from a UTI.

Incorrect diagnoses:

The post-void residual is only 22 mL, which rules out urinary retention. No evidence points to STIs like gonorrhea, nor to incontinence.

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A nurse is assessing a client who has an electrical burn. Which of the following cues should the nurse recognize as indicating a potential complication of the burn injury?

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Naxlex Comprehensive Predictor Exams

Patient presented for follow up of major burn injury. Exhibits A nurse is caring for a client recovering for 12 months from major burns that affected 60% total body surface area (TBSA). Which of the following complications should the nurse expect? (Select all that apply)

Correct Answer is ["B","C","E"]

Explanation

Correct Answer is []

Explanation

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