The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?

Monitor for signs of seizure activity.

Increase the IV rate and monitor for burn shock.

Raise the foot of the bed and apply blankets.

Assess for signs of fluid overload.

Answer and Explanation

The Correct Answer is D

A. Monitor for signs of seizure activity: Seizure activity is not directly related to the condition described.
B. Increase the IV rate and monitor for burn shock: Increasing the IV rate could exacerbate fluid overload; burn shock is more of a concern in the initial hours post-burn.
C. Raise the foot of the bed and apply blankets. This is not relevant to addressing the issue of large urine output.
D. Assess for signs of fluid overload: After the initial fluid resuscitation phase, large urine output may indicate that fluid is being mobilized from the tissues back into the vascular system, potentially leading to fluid overload.

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Correct Answer is C

Explanation

A. Reaction formation involves behaving in a way opposite to one's true feelings, which is not a constructive coping mechanism.
B. Compensation is a coping mechanism where the patient overcomes weaknesses by emphasizing strengths but may not directly address stress.
C. Adaptation involves adjusting and finding effective ways to manage stress and is a positive coping mechanism.
D. Projection involves attributing one's own undesirable thoughts or feelings to others, which is not a healthy way of resolving stress.

A. The darker the patient's skin, the easier it is to assess for color change. B. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation. C. Pallor in black-skinned individuals will appear as a pale pink color. D. Baseline skin color should be assessed in areas with the most pigmentation.

Correct Answer is B

Explanation

A. The darker the patient's skin, the easier it is to assess for color change. Darker skin can make it more challenging to assess color changes, such as pallor or cyanosis.
B. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation. Palpation can help detect changes in texture and warmth, which might be less visible on darker skin.
C. Pallor in black-skinned individuals will appear as a pale pink color. Pallor in dark-skinned individuals often appears as an ashen or gray color, not pink.
D. Baseline skin color should be assessed in areas with the most pigmentation. Baseline skin color should be assessed in normally less pigmented areas like palms and soles for accurate assessment.

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The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?

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