A nurse is planning to complete dressing changes for an adolescent who has multiple burn injuries. Which of the following interventions addresses the greatest risk to the client?
Apply tepid water to the old dressings before removal.
Check the wound sites for manifestations of infection.
Perform passive range-of-motion exercises during the dressing change.
Adjust the room temperature to 33°C (91.4°F).
The Correct Answer is B
Choice A reason: Applying tepid water to the old dressings can help with their removal and may reduce discomfort, but it does not address the greatest risk to the client, which is infection.
Choice B reason: Checking the wound sites for manifestations of infection is crucial as burn injuries compromise the skin's protective barrier, making the client highly susceptible to infections. Infections can lead to further complications and delay healing.
Choice C reason: Performing passive range-of-motion exercises is important for maintaining joint mobility and preventing contractures in burn patients, but it is not the primary intervention for addressing the greatest risk of infection.
Choice D reason: Adjusting the room temperature to 33°C (91.4°F) can create a more comfortable environment for the burn patient and prevent hypothermia, but it is not directly related to the prevention of infection, which is the greatest risk.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: While exposure to secondhand smoke is unhealthy and should be avoided, it is not commonly listed as a trigger for seizures. The primary concern with secondhand smoke is its impact on respiratory health.
Choice Breason: A prolonged headache can be a symptom of various conditions, but it is not generally considered a direct trigger for seizures. However, if a headache is related to a neurological condition, it may be associated with an increased risk of seizures.
Choice Creason: Decreased temperature, or being cold, is not typically a trigger for seizures. Seizure triggers are usually related to changes in the body's internal environment or external stimuli that affect the nervous system.
Choice D reason: Inadequate sleep is a well-known trigger for seizures. Sleep deprivation can lead to increased seizure activity in individuals with seizure disorders. Ensuring adequate and regular sleep is an important part of managing seizure disorders.
Correct Answer is A
Explanation
Choice A reason: This statement is developmentally appropriate and helps to alleviate the child's anxiety about pain during the procedure. It uses language that a 4-year-old can understand without causing unnecessary fear.
Choice B reason: While it is comforting to know a parent will be close by, this statement is not accurate as parents are typically not present in the operating room during the procedure. It could lead to confusion and distress when the parent is not there.
Choice C reason: This statement is too vague and may not be fully understood by a child. It lacks the reassurance that the child will not feel pain, which is an important aspect to address.
Choice D reason: Although this statement is positive and forward-looking, it does not address the child's immediate concerns about the procedure itself. It is important to reassure the child about what to expect during the surgery.
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