The practical nurse (PN) receives a report of a stable client who experienced partial burn thickness over 30% burns body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?
Excruciating pain.
Elevated blood pressure.
Compartment syndrome.
Curling's Ulcer.
The Correct Answer is D
The correct answer is Choice D
Choice A: Excruciating pain
- Rationale: While partial thickness burns can be painful, especially in the first few days, excruciating pain is less likely for a stable patient 3 days post-burn. Pain management is a crucial aspect of burn care, but excruciating pain might indicate deeper burns or complications like infection.
Choice B: Elevated blood pressure
- Rationale: Elevated blood pressure is not a typical complication of a partial thickness burn. In fact, burn patients are more at risk for hypotension (low blood pressure) due to fluid loss.
Choice C: Compartment syndrome
- Rationale: Compartment syndrome is a serious complication that typically occurs with deep burns or traumatic injuries. It's caused by increased pressure within a muscle compartment, restricting blood flow and potentially leading to tissue death. While a possibility, it's less likely for a partial thickness burn 3 days after the injury.
Choice D: Curling's Ulcer
- Rationale: Curling's ulcer is a peptic ulcer (stomach ulcer) that can develop as a complication of major burns. This is because burns trigger a massive inflammatory response, releasing stress hormones that increase stomach acid production, making the stomach lining more susceptible to ulcers. Given the extensive burn area (30% TBSA) and the timeframe (3 days post-burn), Curling's ulcer becomes a significant concern.
Therefore, the correct answer is: Choice D: Curling's Ulcer
Explanation:
- A 30% TBSA partial thickness burn is a significant injury that triggers a systemic inflammatory response.
- Three days post-burn falls within the timeframe when Curling's ulcer can develop due to the increased stress hormones and gastric acid production.
- While pain management and monitoring for compartment syndrome are important, Curling's ulcer poses a more significant threat in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: Record the findings and report the symptoms to the charge nurse.
Choice A rationale:
The practical nurse (PN) should first record the client's findings, including the progressively decreasing appetite, increased daytime bed hours, and refusal to participate in planned activities. This documentation is essential for accurate communication and continuity of care. After recording the findings, the PN should promptly report the symptoms to the charge nurse. Reporting allows for timely intervention and assessment by the charge nurse or other healthcare providers to address the client's issues effectively.
Choice B rationale:
Asking family members to visit more often is not the best action to take in this situation. While family support is important, the client's symptoms suggest possible underlying health concerns that need professional evaluation and management. Relying solely on increased family visits might delay appropriate healthcare interventions.
Choice C rationale:
Motivating the client by offering their favorite foods as a prize might not be appropriate at this stage. The client's decreased appetite and refusal to participate in activities could be indicators of underlying health issues that need to be addressed first. Moreover, encouraging unhealthy eating habits as a "prize”. could be counterproductive to the client's well-being.
Choice D rationale:
Withholding medications that may cause side effects is not a suitable action without consulting the healthcare provider responsible for the client's care. Abruptly stopping medications could lead to adverse effects or complications, and it is essential to involve the healthcare team in making decisions about medication management.
Correct Answer is ["C"]
Explanation
The correct answer is choice C. Initiation of changes in infection control measures.
Choice A rationale:
Limiting the client’s fluid intake to avoid hemodilution is not relevant to managing a decreased ANC. Hemodilution is not a concern in this context, and fluid intake should generally be maintained to support overall health.
Choice B rationale:
Avoiding exposure to cold temperatures is not directly related to managing a decreased ANC. While keeping the client comfortable is important, it does not address the increased risk of infection associated with neutropenia.
Choice C rationale:
Initiation of changes in infection control measures is crucial when a client’s ANC decreases. Neutropenia increases the risk of infections, so enhanced infection control practices, such as strict hand hygiene, use of protective isolation, and monitoring for signs of infection, are essential to protect the client.
Choice D rationale:
Increasing the client’s dietary servings of fruits and vegetables is generally beneficial for overall health but does not specifically address the immediate risks associated with a decreased ANC. In fact, certain fresh fruits and vegetables might need to be avoided if they pose a risk of introducing pathogens.
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