A 38-year-old male is brought into the Emergency Department by ambulance after a car explosion while working in his garage. He was trapped under the hood momentarily and pulled out by a neighbor. He is unconscious, and full-thickness burns are visible on his anterior torso, both arms, and part of his face.

Based on the assessment and wound appearance, what type of burn is this?

First-degree

Third-degree (full thickness)

Second-degree (partial thickness)

Fourth-degree (extends to muscle/bone)

Answer and Explanation

The Correct Answer is D

Rationale:

A. First-degree burns are superficial and involve only the epidermis, presenting as red, painful skin without blisters. This patient’s burns are far more severe and involve deeper structures, so first-degree is incorrect.

B. Third-degree (full-thickness) burns involve the epidermis and dermis, resulting in charred, leathery, painless skin with eschar formation. While the patient shows these features, the presence of exposed muscle and bone indicates the injury extends beyond the dermis, making third-degree incomplete for this scenario.

C. Second-degree (partial-thickness) burns involve the epidermis and part of the dermis, presenting with blisters, red or moist skin, and pain. This patient’s skin is charred, black, dry, and painless, which is inconsistent with partial-thickness burns.

D. Fourth-degree burns are correct because they extend beyond the dermis into muscle, tendons, or bone. The patient has areas exposing muscle and bone, no pain in those areas, and charred, leathery eschar, which are classic findings for fourth-degree burns. These burns are life-threatening and require immediate airway management, fluid resuscitation, and surgical intervention.

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Correct Answer is C

Explanation

Rationale:
A. Overhydration, hypoglycemia, and weight gain is incorrect because weight gain could indicate adequate or excessive caloric intake, and hypoglycemia may be related to other factors such as insulin administration rather than inadequate nutrition. Overhydration is more of a fluid balance issue than a direct indicator of nutrition goals not being met.

B. Hyperglycemia, normovolemia, and increased protein level is incorrect because increased protein levels suggest adequate protein intake. Normovolemia indicates proper fluid status, and while hyperglycemia can occur with parenteral nutrition, it does not alone indicate that nutritional goals are unmet.

C. Weight loss, elevated glucose, and dehydration is correct because weight loss reflects inadequate caloric intake, elevated glucose may indicate poor metabolic control or stress response to inadequate nutrition, and dehydration suggests insufficient fluid intake. These objective findings collectively indicate that nutrition and fluid goals are not being met, which could impair recovery and wound healing.

D. Weight gain, inconsistent glucose, and normovolemia is incorrect because weight gain and normovolemia indicate that at least caloric and fluid needs are partially met. Inconsistent glucose alone does not clearly indicate that nutritional goals are unmet without other signs such as weight loss or protein deficiency.

A. low sodium diet B. fluid restriction C. administration of 36 normal saline. D. administration of exogenous vasopressin.

Correct Answer is B

Explanation

Rationale:
A. Low sodium diet is incorrect because SIADH is characterized by water retention leading to hyponatremia, not sodium excess. Reducing dietary sodium would worsen hyponatremia, so a low sodium diet is contraindicated.

B. Fluid restriction is correct because the primary problem in SIADH is excess water retention due to inappropriate antidiuretic hormone secretion, which dilutes serum sodium. Restricting fluids limits further dilution, helps restore sodium balance, and prevents worsening hyponatremia. Fluid restriction is typically the first-line management in stable patients.

C. Administration of 3% normal saline is incorrect as a routine measure because hypertonic saline is reserved for severe or symptomatic hyponatremia (e.g., seizures, severe confusion). Overuse can cause rapid sodium shifts and central pontine myelinolysis, which is dangerous.

D. Administration of exogenous vasopressin is incorrect because SIADH is caused by excess ADH. Giving additional vasopressin would exacerbate water retention and hyponatremia, worsening the patient’s condition.

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Naxlex Comprehensive Predictor Exams

What are the objective data the nurse identifies indicating that the nutrition goals are not being met?

Correct Answer is C

Explanation

A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. Which clinical management strategy does the nurse anticipate for this condition?

Correct Answer is B

Explanation

The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess?

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According to the articles you read for today's class, ICU syndrome does not differ from delirium.

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Your patient with facial burns from a house fire is being assessed in the Emergency Department. He begins to develop hoarseness, stridor, and difficulty speaking. What is the priority nursing action?