When providing information to a client in the rehabilitative phase of a burn injury, which of the following will the nurse identify as the goal?

Resume a functional role in society

Pain management

Provide continued full support to the client

Prevent infection

Answer and Explanation

The Correct Answer is A

Choice A reason: This is correct because resuming a functional role in society is the ultimate goal for a client in the rehabilitative phase of a burn injury. The rehabilitative phase begins when wound healing is complete and lasts until physical and psychosocial recovery is achieved. The nurse should help the client regain independence, self-esteem, and quality of life by providing education, counseling, referrals, and resources.

Choice B reason: This is incorrect because pain management is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Pain management is important throughout all phases of burn care, but especially during wound healing and scar formation, which can cause itching, tightness, or hypersensitivity. The nurse should assess the client's pain level and administer analgesics, antipruritics, or moisturizers as ordered.

Choice C reason: This is incorrect because providing continued full support to the client is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Providing continued full support to the client can help them cope with physical and emotional challenges, such as scarring, disfigurement, disability, or depression. The nurse should provide emotional support, active listening, positive feedback, and encouragement to the client.

Choice D reason: This is incorrect because preventing infection is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Preventing infection is crucial during wound healing and grafting, which can be compromised by bacterial colonization or contamination. The nurse should monitor the client's vital signs, wound appearance, and laboratory results, and administer antibiotics or antiseptics as ordered.

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Correct Answer is B

Explanation

Choice A Reason: A virus is not detected by the KOH test, which is used to diagnose fungal infections of the skin, hair, or nails. A virus can be detected by other tests, such as polymerase chain reaction (PCR) or viral culture.

Choice B Reason: A fungal infection is detected by the KOH test, which dissolves the skin cells and leaves behind the fungal elements that can be seen under a microscope. A fungal infection can cause symptoms such as itching, scaling, redness, or blisters.

Choice C Reason: A bacterial infection is not detected by the KOH test, which is specific for fungi. A bacterial infection can be detected by other tests, such as gram stain or culture.

Choice D Reason: Cancer is not detected by the KOH test, which is not a screening tool for malignancy. Cancer can be detected by other tests, such as biopsy or imaging.

A. A drop in heart rate from 74 to 68/min. B. A change in the Glasgow Coma Scale score from 14 to 10. C. Headache. D. Diplopia.

Correct Answer is B

Explanation

Choice A reason: This is incorrect because a drop in heart rate from 74 to 68/min is not a manifestation that requires immediate reporting to the provider. A mild decrease in heart rate can be normal or due to other factors such as medication, sleep, or relaxation. It does not indicate a worsening of brain injury or increased intracranial pressure.

Choice B reason: This is the correct answer because a change in the Glasgow Coma Scale score from 14 to 10 is a manifestation that requires immediate reporting to the provider. The Glasgow Coma Scale is a tool that measures the level of consciousness based on eye-opening, verbal response, and motor responses. A score of 14 indicates mild impairment, while a score of 10 indicates moderate impairment. A decrease in score can indicate deterioration of neurological status and increased intracranial pressure, which can be life-threatening.

Choice C reason: This is incorrect because the headache is not a manifestation that requires immediate reporting to
the provider. Headache is a common symptom of mild TBI and can be managed with analgesics, rest, and hydration. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is severe, persistent, or accompanied by other signs such as vomiting, confusion, or seizures.

Choice D reason: This is incorrect because diplopia is not a manifestation that requires immediate reporting to
the provider. Diplopia means double vision and can be caused by damage to cranial nerves or eye muscles due to TBI. It can be treated with eye patches, glasses, or surgery. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is associated with other symptoms such as blurred vision, loss of vision, or eye pain.

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When providing information to a client in the rehabilitative phase of a burn injury, which of the following will the nurse identify as the goal?

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Explanation

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