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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. Initial stage of septic shock

Septic shock typically presents with warm, flushed skin in the early phase due to vasodilation. This client has cold and clammy skin, which is more consistent with hypovolemic shock.

B. Refractory stage of obstructive shock

Obstructive shock (e.g., from cardiac tamponade or pulmonary embolism) would present with jugular vein distention, muffled heart sounds, or severe respiratory distress, which are not seen in this case.

C. Progressive stage of hypovolemic shock

The client has classic signs of hypovolemic shock due to fluid loss (nausea, vomiting, diarrhea). The progressive stage is indicated by hypotension, tachycardia, and end-organ dysfunction (altered mental status, cool/clammy skin).

D. Compensatory stage of diabetic shock

"Diabetic shock" is not a standard classification of shock. The compensatory stage would still have an adequate blood pressure due to SNS activation, but this patient already has profound hypotension.

A. Urine output of less than 0.5mL/kg B. Improved mental status, decreased lactate level C. A mean arterial pressure (MAP) of 65 D. A pain level of 4 or less on a scale of 0-10

Correct Answer is C

Explanation

A. Urine output of less than 0.5 mL/kg

Norepinephrine is a vasopressor used to improve perfusion. A urine output of less than 0.5 mL/kg suggests ongoing hypoperfusion and inadequate organ perfusion, which is an undesirable outcome.

B. Improved mental status, decreased lactate level

These are positive indicators of improved perfusion and oxygen delivery, but they are not the primary target for norepinephrine therapy.

C. A mean arterial pressure (MAP) of 65

A MAP of at least 65 mmHg is the target for vasopressor therapy, as it ensures adequate perfusion of vital organs.

D. A pain level of 4 or less on a scale of 0-10

While pain management is important, norepinephrine’s primary role is not pain control but rather maintaining adequate perfusion.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with hypovolemic shock who did not respond to fluid resuscitation is started on norepinephrine. What is the desired outcome?

Correct Answer is C

Explanation

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