The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)
distributive shock
cardiogenic shock
obstructive shock
hypovolemic shock
neurogenic shock
Correct Answer : A,B
A. Distributive shock
Severe burns lead to systemic inflammatory response syndrome (SIRS), causing massive vasodilation, similar to septic shock (a type of distributive shock).
D. Hypovolemic shock
Fluid loss from burns leads to hypovolemic shock, which is the most common type of shock seen in burn patients.
B. Cardiogenic shock
Cardiogenic shock is caused by heart failure and is not a primary concern in burn injuries.
C. Obstructive shock
Obstructive shock (e.g., tension pneumothorax, cardiac tamponade) does not occur in burn patients unless another condition is present.
E. Neurogenic shock
Neurogenic shock occurs from spinal cord injuries, not burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wearing sunglasses while symptomatic
Sunglasses reduce photophobia, but they do not prevent corneal damage from dryness.
B. Applying an eye patch before sleep
Bell's palsy affects cranial nerve VII (facial nerve), leading to incomplete eye closure. This can cause corneal abrasions and dryness. An eye patch at night prevents corneal injury.
C. An antihistamine eye drop
Antihistamine eye drops may dry out the eye further, worsening the risk of corneal injury.
D. Antibiotic ophthalmic ointment
Antibiotics are not necessary unless an infection is present. Lubricating drops or artificial tears are more appropriate.
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.
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