A nurse is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
"A piece of healthy skin will be removed from an unburned area and grafted over the burned area."
"This procedure involves placing the client into a Whirlpool tub and removing the dead tissue."
"Dead tissue will be non-surgically removed."
"Incisions will be made in the burnt tissues to improve circulation."
The Correct Answer is D
A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not escharotomy.
B. "This procedure involves placing the client into a Whirlpool tub and removing the dead tissue.": This describes hydrotherapy or wound debridement.
C. "Dead tissue will be non-surgically removed.": Describes enzymatic or mechanical debridement.
D. "Incisions will be made in the burnt tissues to improve circulation.": Escharotomy relieves pressure caused by tight, burned skin (eschar) to restore blood flow and prevent compartment syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds: High-pitched respiratory sounds (stridor) suggest impending airway obstruction, which is life-threatening and requires immediate intervention.
B. Client with facial burns and expectorating sooty secretions in no distress: At risk for inhalation injury but not in immediate respiratory distress.
C. Client with dry, black skin on both hands and a history of diabetes mellitus: Eschar and possible full-thickness burns are serious but not immediately life-threatening compared to airway compromise.
D. Client with moist blisters over the back and who reports pain as 10: Pain is expected and manageable; airway takes priority.
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.
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