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A nurse is assessing a patient who sustained partial-thickness burns to the anterior chest and anterior left arm. Using the Rule of Nines, what percentage of total body surface area (TBSA) is affected?

22.5%

13.5%

18%

Answer and Explanation

The Correct Answer is B

A. 22.5%. This overestimates the affected TBSA based on the Rule of Nines.

B. 13.5%. Using the Rule of Nines:

Anterior chest = 9%
Anterior left arm = 4.5%
Total TBSA = 9% + 4.5% = 13.5%

C. 9%. This would account only for the anterior chest but does not include the anterior left arm.

D. 18%. This would be correct if both the anterior and posterior chest were involved, but the question specifies only the anterior chest and left arm.

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Correct Answer is D

Explanation

A. Poor personal hygiene. SJS is not caused by poor hygiene. It is a severe hypersensitivity reaction, most often triggered by medications or infections.

B. A family history of autoimmune disorders. While some autoimmune conditions may predispose individuals to skin disorders, SJS is primarily a reaction to medications or infections rather than an inherited autoimmune condition.

C. Chronic sun exposure. Chronic sun exposure is associated with conditions like actinic keratosis and skin cancers, not SJS.

D. A recent course of antibiotics. Medications, especially antibiotics (e.g., sulfonamides), anticonvulsants, and NSAIDs, are the most common triggers of SJS. This severe reaction results in widespread skin detachment and mucosal involvement.

A. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). B. Increased heart rate from 68 to 72/min. C. Increased respiratory rate from 18 to 44/min. D. Increased blood pressure from 112/68 to 120/72 mm Hg

Correct Answer is C

Explanation

A. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). A slight temperature increase is expected post-injury due to normal inflammatory response and does not indicate a serious complication.

B. Increased heart rate from 68 to 72/min. This small increase in heart rate is not clinically significant and does not indicate a serious complication.

C. Increased respiratory rate from 18 to 44/min. A sudden increase in respiratory rate could indicate a fat embolism, a life-threatening complication associated with long bone fractures. Fat emboli can travel to the lungs, causing respiratory distress. Immediate intervention is required.

D. Increased blood pressure from 112/68 to 120/72 mm Hg. This small increase in blood pressure is not alarming and does not indicate a serious complication.

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A nurse is assessing a patient who sustained partial-thickness burns to the anterior chest and anterior left arm. Using the Rule of Nines, what percentage of total body surface area (TBSA) is affected?

Nursing Test Bank

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