Patient presented for follow up of major burn injury.

Exhibits
A nurse is caring for a client recovering for 12 months from major burns that affected 60% total body surface area (TBSA). Which of the following complications should the nurse expect? (Select all that apply)

Fluid volume deficit

Symptoms of Post traumatic

Depression

Electrolyte imbalances

Body image disorder

Answer and Explanation

Correct Answer : B,C,E

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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Correct Answer is A

Explanation

A. Administering sodium polystyrene sulfonate:
This medication removes potassium through the GI tract and is used to treat hyperkalemia.

B. Initiating an IV potassium infusion:
The client already has hyperkalemia; giving potassium would worsen it.

C. Administering a potassium-sparing diuretic:
These medications retain potassium and would further elevate potassium levels.

D. Encouraging the client to eat bananas:
Bananas are high in potassium and should be avoided in hyperkalemia.

A. Place the drainage bag above the level of the client's abdomen. B. Warm the dialysate solution prior to instillation. C. Monitor vital signs every 2 hours during the procedure. D. Maintain the client in a left lateral position during dialysis.

Correct Answer is B

Explanation

A. Place the drainage bag above the level of the client's abdomen: This would impede drainage by gravity. The drainage bag should be below abdominal level to promote outflow.

B. Warm the dialysate solution prior to instillation: Warming the solution enhances diffusion, promotes comfort, and prevents abdominal cramping. Use a warming pad, not a microwave.

C. Monitor vital signs every 2 hours during the procedure: While vital signs are monitored, more frequent monitoring is often required during the initial phase or if the patient is unstable.

D. Maintain the client in a left lateral position during dialysis: The semi-Fowler’s position is preferred to facilitate flow and lung expansion, not lateral positioning.

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Patient presented for follow up of major burn injury. Exhibits A nurse is caring for a client recovering for 12 months from major burns that affected 60% total body surface area (TBSA). Which of the following complications should the nurse expect? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Patient presented for follow up of major burn injury.

Exhibits
A nurse is caring for a client recovering for 12 months from major burns that affected 60% total body surface area (TBSA). Which of the following complications should the nurse expect? (Select all that apply)