A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small, the burn must not be too bad. Which of the following is the best response by the nurse?
Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
Electrical burns commonly cause reddened/purplish skin without blistering.
Electrical burns typically are minor.
Electrical burns usually cause much more skin damage than what can be seen on your skin.
The Correct Answer is A
A. Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
This response is the best choice because it educates the client about the potential for deeper tissue damage associated with electrical burns. It acknowledges that while the burn on the skin may appear small, the damage underneath could be more extensive, affecting muscles, nerves, and blood vessels.
B. Electrical burns commonly cause reddened/purplish skin without blistering.
This statement is not the best response because it focuses solely on the appearance of the skin without addressing the potential for deeper tissue damage. While it is true that electrical burns can present with reddened or purplish skin without blistering, this response does not provide comprehensive information about the nature and severity of electrical burns.
C. Electrical burns typically are minor.
This response is incorrect because it downplays the seriousness of electrical burns. While some electrical burns may indeed be minor, others can cause significant tissue damage and complications. It's important for the nurse to educate the client about the range of severity that electrical burns can present.
D. Electrical burns usually cause much more skin damage than what can be seen on your skin.
This statement is partially accurate but does not provide as much information as choice A. While it acknowledges that electrical burns can cause more damage than what is visible on the skin's surface, it doesn't emphasize the potential for deeper tissue damage as effectively as choice A does.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Decreased plasma volume:Burn injuries cause a significant inflammatory response, leading to fluid shifts from the intravascular space to the interstitial space. This results in hypovolemia and decreased plasma volume, especially during the acute phase of burns.
B. Diuresis:Diuresis typically occurs after fluid resuscitation and stabilization of the client (in the later phase of burn recovery). In the initial phase, oliguria is more common due to hypovolemia and reduced renal perfusion.
C. Hypermagnesemia:Hypermagnesemia is not typically associated with burn injuries. Instead, clients with burns often experience hypomagnesemia due to fluid shifts, protein loss, and increased renal losses.
D. Capillary leak:Burn injuries lead to a systemic inflammatory response, causing capillary leak syndrome. This increases vascular permeability, allowing fluid, electrolytes, and proteins to leak into the interstitial spaces, contributing to edema and hypovolemia.
E. Loss of protein:Proteins are lost through damaged capillaries and open burn wounds, contributing to decreased oncotic pressure, edema, and a need for aggressive nutritional support to promote healing and recovery.
Correct Answer is D
Explanation
A. Diabetic ketoacidosis (DKA) in a person with emphysema:
In DKA, there is typically metabolic acidosis due to the accumulation of ketones in the blood, leading to a decrease in pH. However, the respiratory compensation mechanism in DKA usually results in a decreased PaCO2 (respiratory alkalosis) rather than an elevated PaCO2 as seen in the blood gas values provided. Additionally, emphysema is associated with chronic respiratory acidosis, not respiratory alkalosis as indicated by the elevated PaCO2.
B. Diarrhea for 36 hours in an older, frail woman:
Prolonged diarrhea can lead to metabolic acidosis due to the loss of bicarbonate through the gastrointestinal tract. The pH of 7.12 and the decreased HCO3- (22 mEq/L) suggest metabolic acidosis. However, the elevated PaCO2 (respiratory acidosis) is not consistent with pure metabolic acidosis caused by diarrhea. Respiratory acidosis typically occurs due to hypoventilation or respiratory dysfunction.
C. Anxiety-induced hyperventilation in an adolescent:
Anxiety-induced hyperventilation can lead to respiratory alkalosis due to excessive blowing off of CO2, resulting in a decrease in PaCO2. The pH of 7.12 is consistent with acidosis, but the elevated PaCO2 contradicts respiratory alkalosis. Anxiety-induced hyperventilation would typically result in a higher pH and lower PaCO2.
D. Bronchial obstruction related to aspiration of a hot dog:
A bronchial obstruction causing inadequate ventilation can lead to respiratory acidosis due to CO2 retention. The pH of 7.12 and the elevated PaCO2 (65 mm Hg) indicate respiratory acidosis. This situation is consistent with the blood gas values provided.
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