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For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed?
(Select All that Apply.)

Causative agent and duration of exposure

Depth of burn

Anatomical location of burns on the body

Total Body Surface Area (TBSA) percentage

Time of day burn occurred

Answer and Explanation

Correct Answer : A,B,C,D

A. Causative agent and duration of exposure – Chemical, electrical, or thermal burns differ in severity.

B. Depth of burn – Superficial, partial-thickness, and full-thickness burns determine severity.

C. Anatomical location – Burns over joints, face, or perineum have higher morbidity.

D. Total Body Surface Area (TBSA) percentage – Used to estimate fluid resuscitation needs (e.g., Parkland formula).

E. Time of day burn occurred – Time does not affect burn severity.

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Correct Answer is C

Explanation

A. Monitoring for dysrhythmias
While cardiovascular health is important, dysrhythmias are not a primary concern in a small abdominal aortic aneurysm.

B. Monitoring for bleeding
While aneurysms can rupture, a small aneurysm is managed medically with blood pressure control, making bleeding less of an immediate concern.

C. Adherence to their antihypertensive drugs
Hypertension increases pressure on the aneurysm, increasing the risk of expansion and rupture. Strict adherence to antihypertensive medications is essential for preventing complications.

D. Preventing thrombus formation
While thrombus formation can occur in large aneurysms, it is not the primary focus in a small, medically managed aneurysm.

A. Decrease chest pain B. Reduce the client's anxiety C. Maintain adequate circulating volume D. Maintain adequate oxygenation

Correct Answer is D

Explanation

A. Decrease chest pain is important but not the highest priority. Managing pain can help with breathing, but oxygenation is the primary concern.

B. Reduce the client's anxiety is secondary to physiological needs. Anxiety can worsen dyspnea, but addressing oxygenation first is more critical.

C. Maintain adequate circulating volume is a priority if there is hemorrhage, but the question does not indicate bleeding. Oxygenation takes precedence in this case.

D. Maintain adequate oxygenation is the priority. Chest trauma can lead to pneumothorax, pulmonary contusion, or other complications that can impair gas exchange. Ensuring adequate oxygenation prevents hypoxia and respiratory failure, which are life-threatening.

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For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has an abdominal aortic aneurysm. The physician explains to the client that the aneurysm is small and that the client will be managed medically. Based on this information, it is most important that the nurse reinforces discharge teaching about:

Correct Answer is C

Explanation

A young adult is admitted to the emergency department after a motor vehicle crash. The client has severe pain in the right chest due to impact with the steering wheel. Which is the priority client goal?

Correct Answer is D

Explanation

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For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed?
(Select All that Apply.)