A client has decreased glomerular filtration due to vasoconstriction of the afferent arteriole. What outcome should the nurse anticipate?

Rationale:

A. The rule of nines is a method for calculating gestational age during pregnancy is incorrect. Gestational age is determined using methods such as the last menstrual period, early ultrasound measurements, or fetal biometry, which assess fetal growth and development. The rule of nines has no role in obstetrics and does not provide any information about pregnancy duration or fetal maturity.

B. The rule of nines is used to determine the ideal body weight based on height and weight calculations is incorrect. Ideal body weight calculations rely on formulas like the Devine or Hamwi equations, which consider height, sex, and sometimes body frame size. The rule of nines does not involve body weight, body mass index, or nutritional assessment, so it cannot be used for this purpose.

C. The rule of nines is used to estimate burn depth and healing potential of a burn wound is partially incorrect. While assessing burn depth and healing potential is important in burn care, the rule of nines specifically addresses only the total body surface area (TBSA) affected by burns. Burn depth is evaluated separately by examining skin layers involved, color, sensation, and tissue viability. Therefore, this statement inaccurately conflates burn depth assessment with the TBSA estimation function of the rule of nines.

D. The rule of nines divides the body into multiples of nine to estimate the percentage of total body surface area burned is correct. In adults, the body is divided into regions representing roughly 9% or multiples of 9% of TBSA, including the head and neck (9%), each arm (9%), each leg (18%), anterior torso (18%), posterior torso (18%), and perineum (1%). This method allows rapid, standardized estimation of burn size, which is critical for fluid resuscitation, monitoring for complications, and treatment planning in burn patients.

Rationale:

A. Inhalation injury is a serious complication of severe burns, especially those involving the face, neck, or upper torso, or occurring in a fire with smoke or toxic fumes. Thermal or chemical injury to the respiratory tract can cause airway edema, bronchospasm, and impaired gas exchange, which can be life-threatening if not promptly managed.

B. Contractures can develop during the healing process of deep partial-thickness or full-thickness burns. Scar tissue and skin grafts can limit joint mobility, leading to permanent deformities if proper positioning, physical therapy, and splinting are not implemented.

C. Hypovolemic shock is a common early complication of severe burns. Extensive burn injuries cause massive fluid loss through damaged skin and increased capillary permeability, leading to decreased circulating blood volume, hypotension, and organ hypoperfusion. Immediate fluid resuscitation is critical to prevent shock and organ failure.

D. Hearing loss is not a recognized complication of burn injuries. Burns typically do not affect the auditory system unless there is a direct traumatic injury to the ears, which is rare.

E. Increased muscle mass is incorrect. Severe burns are associated with catabolism, muscle wasting, and negative nitrogen balance due to hypermetabolic stress, not increased muscle mass.

F. Infection is a major risk in burn patients because the skin barrier is destroyed, providing a portal for bacteria, fungi, and viruses. Burn wounds are highly susceptible to local infections and sepsis, which is a leading cause of morbidity and mortality in severe burn injuries.