Age-Related Changes and Burn Injury Management, Exams of Nursing

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Nursing Exam 4 Burns and Perfusion Correctly

Solved Questions with Answers

1. The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor? A. An insect bite B. Dehydration C. Sunburn D. Excessive perspiration: ANS: A Rationale: The stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, such as chemicals, microbes, insect bites, and other trauma. Dehydration, sunburn, and excessive perspiration are not examples of penetration of an environ- mental factor. 2. A nurse is reviewing gerontologic considerations relating to the care of clients with dermatologic problems. What vulnerability results from the age- re- lated loss of subcutaneous tissue? A. Decreased resistance to ultraviolet radiation B. Increased vulnerability to infection C. Diminished protection of tissues and organs D. Increased risk of skin malignancies: ANS: C Rationale: Loss of the subcutaneous tissue substances of elastin, collagen, and fat diminishes the protection and cushioning of underlying tissues and organs, decreases muscle tone, and results in the loss of the

insulating properties of fat. This age-related change does not correlate to an increased vulnerability to sun damage, infection, or cancer.

3. An 80-year-old client is brought to the clinic by one of the client's children. The client asks the nurse why the client has gotten so many "spots" on the skin. What would be an appropriate response by the nurse? A. "As people age, they normally develop uneven pigmentation in their skin." B. "These 'spots' are called 'liver spots' or 'age spots.'" C. "Older skin is more apt to break down and tear, causing sores." D. "These are usually the result of nutritional deficits earlier in life.": ANS: A Rationale: The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Stating the names of these spots and identifying older adults' vulnerability to skin damage do not answer the question. These lesions are not normally a result of nutritional imbalances. 4. A gerontologic nurse is teaching a group of nursing students about integu- mentary changes that occur in older adults. How should these students best integrate these changes into care planning? A. By avoiding the use of moisturizing lotions on older adults' skin B. By protecting older adults against shearing injuries C. By avoiding the use of ice packs to treat muscle pain D. By protecting older adults against excessive sweat accumulation: ANS: B Rationale: Cellular changes associated with aging include thinning at the junction of the dermis and epidermis, which creates a risk for shearing injuries. Moisturizing lotions can be safely used to address the increased dryness of older adults' skin. Ice packs can be used, provided

skin is assessed regularly and the client possesses normal sensation. Older adults perspire much less than younger adults, thus sweat accumulation is rarely an issue.

5. A nurse is explaining the importance of sunlight on the skin to a client with decreased mobility who rarely leaves the house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? A. E B. D C. A D. C: ANS: B Rationale: Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). Vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus. 6. An 82-year-old client is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the client's course of treatment? A. Increased thickness of the subcutaneous skin layer B. Increased vascular supply to superficial skin layers C. Changes in the character and quantity of bacterial skin flora D. Increased time required for wound healing: ANS: D Rationale: Wound healing becomes slower with age, requiring more time for older adults to recover from surgical and traumatic wounds.

There are no changes in skin flora with increased age. Vascular supply and skin thickness both decrease with age.

7. A nurse is reviewing gerontologic considerations relating to the care of clients with dermatologic problems. What vulnerability results from the age- re- lated loss of subcutaneous tissue? A. Decreased resistance to ultraviolet radiation B. Increased vulnerability to infection C. Diminished protection of tissues and organs D. Increased risk of skin malignancies: ANS: C Rationale: Loss of the subcutaneous tissue substances of elastin, collagen, and fat diminishes the protection and cushioning of underlying tissues and organs, decreases muscle tone, and results in the loss of the insulating properties of fat. This age-related change does not correlate to an increased vulnerability to sun damage, infection, or cancer. 8. The nurse is performing an initial assessment of a client who has a raised, pruritic rash. The client denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this client at this time? A. "Is anyone in your family allergic to anything?" B. "How long have you had this abrasion?" C. "Do you take any over-the-counter (OTC) drugs or herbal preparations?" D. "What do you do for a living?": ANS: C Rationale: If suspicious areas are noted, the client is questioned about nonprescrip- tion or herbal preparations that might be in use.

Ascertaining a family history of allergies would not give helpful information at this time. The client's lesion is not described as an abrasion. The client's occupation may or may not be relevant; it is more important to assess for herb or drug reactions.

9. The nurse is performing a comprehensive assessment of a client's skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way? A. By examining the client under a Wood light B. By inspecting the client's skin in direct sunlight C. By palpating the client's skin D. By performing percussion of major skin surfaces: ANS: C Rationale: Inspection and palpation are techniques commonly used in examining the skin. A client would only be examined under a Wood light if there were indications it could be diagnostic. The client is examined in a well-lit room, not in direct sunlight. Percussion is not a technique used in assessing the skin. 10. A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation? A. Telangiectasias B. Ecchymoses C. Purpura D. Urticaria: ANS: B Rationale: Telangiectasias consist of red marks on the skin caused by

stretching of superficial blood vessels. Ecchymoses are bruises, and purpura consists of pinpoint hemorrhages into the skin. Urticaria is wheals or hives.

11. While assessing a dark-skinned client at the clinic, the nurse notes the presence of patchy, milky-white spots. The nurse knows that this finding is characteristic of what diagnosis? A. Cyanosis B. Addison disease C. Polycythemia D. Vitiligo: ANS: D Rationale: With cyanosis, nail beds are dusky. With polycythemia, the nurse notes ruddy blue face, oral mucosa, and conjunctiva. A bronzed appearance, or "external tan," is associated with Addison disease. Vitiligo is a condition characterized by destruction of the melanocytes in circumscribed areas of skin and appears in light or dark skin as patchy, milky-white spots, often symmetric bilaterally. 12. A nurse is conducting a health interview and is assessing for integumen- tary conditions that are known to have a genetic component. What assess- ment question is most appropriate? A. "Does anyone in your family have eczema or psoriasis?" B. "Have any of your family members been diagnosed with malignant melanoma?" C. "Do you have a family history of vitiligo or port-wine stains?" D. "Does any member of your family have a history of keloid scarring?": ANS: A

Rationale: Eczema and psoriasis are known to have a genetic component. This is not true of any of the other listed integumentary disorders.

13. A client is brought to the emergency department from the site of a chemical fire, where the client suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm? A. Superficial partial thickness B. Deep partial thickness C. Full partial thickness D. Full thickness: ANS: D Rationale: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial- thickness burns involve the epidermis and possibly a portion of the dermis; the client will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the client will report pain and sensitivity to cold air. Full partial thickness is not a depth of burn. 14. A nurse has reported for a shift at a busy burns and plastics unit in a

large university hospital. Which client is most likely to have life- threatening complications? A. A 4-year-old scald victim burned over 24% of the body B. A 27-year-old male burned over 36% of his body in a car accident C. A 39-year-old female client burned over 18% of her body D. A 60-year-old male burned over 16% of his body in a brush fire: ANS: A Rationale: Young children and older adults continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the client.

15. An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? A. The length of time since the burn B. The location of burned skin surfaces C. The source of the burn D. The total body surface area (TBSA) affected by the burn: ANS: D Rationale: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects. 16. An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of

burn? A. The causative agent B. The client's pre-injury health status C. The client's prognosis for recovery D. The circumstances of the accident: ANS: A Rationale: The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temper- ature of the burning agent, duration of contact with the agent, and thickness of the skin. The client's pre-injury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn.

17. A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication? A. Psychosis B. Posttraumatic stress disorder C. Delirium D. Vascular dementia: ANS: B Rationale: Posttraumatic stress disorder (PTSD) is the most common psychiatric disorder in burn survivors, with a prevalence that may be as high as 45%. As a result, it is important for the nurse to assess for this complication of burn injuries. Psychosis, delirium, and dementia are not among the noted psychiatric and psychosocial complications of burns.

18. A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what findings? A. Hyperkalemia, hyponatremia, elevated hematocrit B. Hypokalemia, hypernatremia, decreased hematocrit C. Hyperkalemia, hypernatremia, decreased hematocrit D. Hypokalemia, hyponatremia, elevated hematocrit: ANS: A Rationale: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, and hemoconcentration that leads to an increased hematocrit. 19. A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what event? A. Hemodynamic instability B. Gastrointestinal hypermotility C. Respiratory arrest D. Hypokalemia: ANS: A Rationale: The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI

changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery.

20. An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large- bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A. Administer IV fluids. B. Administer broad-spectrum antibiotics. C. Administer IV potassium chloride. D. Administer packed red blood cells.: ANS: A Rationale: Pathophysiologic changes resulting from major burns during the initial burn-shock period include massive fluid losses. Addressing these losses is a major priority in the initial phase of treatment. Antibiotics and PRBCs are not normally given. Potassium chloride would exacerbate the client's hyperkalemia. 21. A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A. Pain

B. Fluid balance C. Anxiety and fear D. Airway management: ANS: D Rationale: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early post-burn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

22. A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? A. Confusion B. High fever C. Decreased blood pressure D. Sudden agitation: ANS: C Rationale: As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation. 23. A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? A. Fluid status

B. Risk of infection C. Nutritional status D. Psychosocial coping: ANS: A Rationale: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

24. An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? A. Apply ice to the site of the burn for 5 to 10 minutes. B. Wrap the client's affected extremity in ice until help arrives. C. Apply an oil-based substance to the burned area until help arrives. D. Wrap cool towels around the affected extremity intermittently.: ANS: D Rationale: Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain, and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Oils are contraindicated.

25. A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruc- tion, despite appearing stable since admitted. How should the client's change in status be best understood? A. The client is likely experiencing a delayed onset of respiratory complica- tions B. The client has likely developed a systemic infection C. The client's respiratory complications are likely related to psychosocial stress D.The client is likely experiencing an anaphylactic reaction to a medication: - ANS: A Rationale: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. A systemic infection would be less likely to cause respiratory complications. This problem is more likely to be caused by physiologic factors at this phase, not psychological factors. Anaphylaxis must be ruled out, but it is less likely than a response to the initial injury. 26. A client experienced a 33% TBSA burn 72 hours ago. The nurse observes that the client's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A. Obtain an order to reduce the rate of the client's IV fluid infusion. B. Report the client's early signs of acute kidney injury (AKI). C. Recognize that the client is experiencing an expected onset of diuresis. D. Administer sodium chloride as prescribed to compensate for this fluid loss.: ANS: C

Rationale: As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI.

27. A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs? A. A client-controlled analgesia (PCA) system B. Oral opioids supplemented by NSAIDs C. Distraction and relaxation techniques supplemented by NSAIDs D. A combination of benzodiazepines and topical anesthetics: ANS: A Rationale: The goal of treatment is to provide a long-acting analgesic that will provide even coverage for this long-term discomfort. It is helpful to use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the client. The use of client-controlled analgesia (PCA) gives control to the client and achieves this goal. Clients cannot normally achieve adequate pain control without the use of opioids, and parenteral administration is usually required. 28. A client has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the health care provider to order for the wound? A. Silver sulfadiazine 1% (Silvadene) water-soluble cream B. Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C. Silver nitrate 0.5% aqueous solution

D. Acticoat: ANS: B Rationale: Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there is a need to penetrate thick eschar. Silver products do not penetrate eschar; Acticoat is a type of silver dressing.

29. The nurse is providing education to a client that is scheduled for mechan- ical debridement of a wound. The nurse knows that mechanical debridement involves which element? A. A spontaneous separation of dead tissue from the viable tissue B. Removal of eschar until the point of pain and bleeding occurs C. Shaving of burned skin layers until bleeding, viable tissue is revealed D. Early closure of the wound: ANS: B Rationale: Mechanical debridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical debridement can also be accomplished through the use of topical enzymatic debridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural debridement. Shaving the burned skin layers and early wound closure are examples of surgical debridement. 30. A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A. Perform mechanical debridement to remove the exudate and prevent further infection. B. Inform the primary care provider promptly because the graft may need to be removed.

C. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. D. Document this finding as an expected phase of graft healing.: ANS: B Rationale: An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem, and the nurse would not independently perform debridement.

31. A nurse who is taking care of a client with burns is asked by a family member why the client is losing so much weight. The client is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A. "The client is on a calorie-restricted diet in order to divert energy to wound healing." B. "The client's body has consumed fat deposits for fuel because calorie intake is lower than normal." C. "The client actually hasn't lost weight. Instead, there's been a change in the distribution of body fat." D. "The client lost many fluids while being treated in the emergency phase of burn care.": ANS: B Rationale: Clients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Clients are not

placed on a calorie restriction during recovery, and fluid losses would not account for weight loss later in the recovery period. Changes in the overall distribution of body fat do not occur.

32. A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A. Activity intolerance B. Anxiety C. Ineffective coping D. Acute pain: ANS: D Rationale: Pain is inevitable during recovery from any burn injury. Pain in the burn client has been described as one of the most severe types of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid, the presence of pain may contribute to these diagnoses. Management of the client's pain is the priority, as it may have a direct correlation to the other listed nursing diagnoses. 33. A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A. Monitoring fluid and electrolyte imbalances B. Providing education to the client and family

C. Treating infection D. Promoting thermoregulation: ANS: B Rationale: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery.

34. A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A. Assess the client for signs of electrolyte imbalances. B. Administer fluids as prescribed. C. Assess the risk for injury recurrence. D. Assess the client's psychosocial state.: ANS: D Rationale: Recovery from burns can be psychologically challenging; the nurse's as- sessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance. 35. The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk? A. Apply skin emollients as prescribed after granulation has occurred. B. Keep injured areas immobilized whenever possible to promote healing. C. Administer oral or IV corticosteroids as prescribed. D. Encourage physical activity and range-of-motion exercises.: ANS: D

Rationale: Exercise and the promotion of mobility can reduce the risk of contracture and hypertrophic scarring. Skin emollients are not normally used in the treatment of burns, and these do not prevent scarring. Steroids are not used to reduce scarring, as they also slow the healing process.

36. A nurse who provides care on a burn unit is preparing to apply a client's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A. Apply the new ointment without disturbing the existing layer of ointment. B. Apply the ointment using a sterile tongue depressor. C. Apply a layer of ointment approximately 1/16 inch thick. D. Gently irrigate the wound bed after applying the antibiotic ointment.: ANS: C Rationale: After removing the old ointment from the wound bed, the nurse should apply a layer of ointment 1/16-inch thick using clean gloves. The wound would not be irrigated after application of new ointment. 37. A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A. To prevent neuropathies B. To prevent wound breakdown C. To prevent contractures D. To prevent heterotopic ossification: ANS: C Rationale: To prevent the complication of contractures, the nurse will

establish a goal to maintain position of joints in alignment. Gentle range-of-motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

38. A nurse is teaching a client with a partial-thickness wound how to wear the elastic pressure garment. How often should the nurse instruct the client to wear this garment? A. 4 to 6 hours a day for 6 months B. During waking hours for 2 to 3 months after the injury C. Continuously D. At night while sleeping for a year after the injury: ANS: C Rationale: Elastic pressure garments are worn continuously (i.e., 24 hours a day). 39. A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response? A. "That's something that you and your doctor will likely talk about after your scars mature." B. "That is something for you to talk to your doctor about because it's not a nursing responsibility." C. "I know this is really important to you, but you have to realize that no one can make you look like you used to."

D. "Unfortunately, it's likely that these scars will look like this for the rest of your life.": ANS: A Rationale: Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Even though this is not a nursing responsibility, the nurse should still respond appropriately to the client's query. It is true that the client will not realistically look like he or she used to, but this does not instill hope.

40. A 6-year-old boy has been admitted to the hospital with burns. The nurse notes carbonaceous sputum. What action would be the priority? A) Determining the burn depth B) Eliciting a description of the burn C) Estimating burn extent D) Ensuring a patent airway: Ans: D Carbonaceous sputum is a sign of potential airway injury due to smoke inhalation. Therefore, the nurse should ensure a patent airway while obtaining a brief history and simultaneously evaluating the child and providing emergency care. If the burn does not pose an immediate, life- threatening risk, the nurse would obtain an in depth history and elicit a description of the burn. Determining the burn depth and extent are part of the secondary survey. 41. The nurse is caring for a 15-year-old boy who has sustained burn injuries. The nurse observes the burn developing a purplish color with discharge and a foul odor. The nurse suspects which infection? A) Burn wound cellulitis B) Invasive burn cellulitis

C) Burn impetigo D) Staphylococcal scalded skin: Ans: B Feedback: Invasive burn cellulitis results in the burn developing a dark brown, black, or purplish color with a discharge and foul odor. In burn wound cellulitis, the are around the burn becomes increasingly red, swollen, and painful early in the course of burn management. Burn impetigo is characterized by multifocal, small, superficial abscesses. Staphylococcal scalded skin syndrome is not a burn infection; however, it is managed similarly to burns.

42. When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include? A) Administration of colloid initially followed by a crystalloid B) Determination of fluid replacement based on the type of burn C) Administration of most of the volume during the first 8 hours D) Monitoring of hourly urine output to achieve less than 1 mL/kg/hr: Ans: C Feedback: With fluid replacement therapy, most of the volume is administered during the first 8 hours. Crystalloids (such as Ringer lactate) are administered for the first 24 hours, and then colloids are used once capillary permeability is less of a concern. Fluid replacement is determined by the amount of body surface area burned. Hourly urine output is expected to be at least 1 mL/kg/hr 43. A nurse is performing a primary survey on a child who has sustained partial thickness burns over his upper body areas. What action should the nurse take first?

A) Inspect the child's skin color. B) Assess for a patent airway. C) Observe for symmetric breathing. D) Palpate the child's pulse: Ans: B Feedback: When performing a primary survey, the nurse first assesses the child's airway for patency and then intervenes accordingly to ensure that the airway is patent. Next the nurse would evaluate the child's skin color, respiratory effort, and symmetry of breathing and breath sounds. Then the nurse would determine the pulse strength, perfusion status, and heart rate.

44. A 3-year-old child has sustained severe burns and is ordered to receive 100% oxygen. What would the nurse use to administer the oxygen? A) Nasal cannula B) Venturi mask C) Nonrebreather mask D) Oxygen hood: Ans: C All children with severe burns should receive 100% oxygen via a nonrebreather mask or bag--valve--mask ventilation. A nasal cannula provides only low oxygen concentrations (22% to 44%); a Venturi mask provides only 24% to 50% oxygen concentrations. An oxygen hood is used for infants only. 45. A 4-year-old is brought to the emergency department with a burn. What would alert the nurse to the possibility of child abuse? A) Burn assessment correlates with mother's report of contact with a

portable heater. B) Parents state that the injury occurred approximately 15 to 20 minutes ago. C) Clear delineations are noted between burned and non-burned skin areas. D) The burn area appears asymmetric and nonuniform.: Ans: C Feedback: Suggested signs of a burn resulting from possible child abuse include a uniform appearance of the burn with clear delineations of burned and non-burned areas. Abuse would also be suspected if the report of the injury was inconsistent with burn injury or there was a delay in seeking treatment. An asymmetric nonuniform burn often correlates with a splatter-type burn resulting from the child pulling a source of hot fluid onto himself or herself

46. A nurse is preparing a presentation for a local parent group about burn prevention and care in children. What would the nurse be least likely to include in the presentation when describing how to care for a superficial burn? A) Using cool water over the burned area until the pain lessens B) Applying ice directly to the burned skin area C) Covering the burn with a clean, nonadhesive bandage D) Giving the child acetaminophen for pain relief: Ans: B Feedback: With a superficial burn, ice should not be applied to the skin. Using cool water over the burn area; covering with a clean, nonadhesive bandage; and using acetaminophen for pain relief are appropriate to include in the presentation. 47. The mother of a 15-year-old girl has contacted the clinic to report that