A client in the rehabilitative phase of a burn injury has healed graft sites and is beginning mobility exercises.
Which intervention is most important to minimize scarring and promote functional recovery?

Perform daily dressing changes to the healed graft sites.

Applying continuous compression wraps or garments as prescribed.

Increase protein intake to support muscle development and tissue repair.

Limit movement to prevent pain and avoid tension on the healed skin.

Answer and Explanation

The Correct Answer is B

Wound healing and rehabilitative nursing require applying knowledge of collagen synthesis and hypertrophic scarring pathophysiology. Understanding how mechanical pressure influences tissue remodeling is essential for selecting the most effective intervention to promote functional recovery and aesthetic outcomes in burn survivors.

Choice A rationale

Daily dressing changes are generally unnecessary for fully healed graft sites and can cause mechanical irritation to fragile new epithelium. Once grafts are stable, the focus shifts from wound coverage to skin hydration and scar management techniques.

Choice B rationale

Continuous compression garments apply consistent pressure that realigns collagen fibers and reduces myofibroblast activity. This prevents the development of hypertrophic scars and contractures, which are major complications that can severely limit range of motion and functional recovery.

Choice C rationale

While high protein intake is vital during the acute healing phase to support tissue repair, it does not directly prevent scarring once the grafts have already healed. Compression therapy is more specific for managing scar tissue maturation.

Choice D rationale

Limiting movement promotes the development of joint contractures and muscle atrophy. Controlled mobility and stretching exercises are critical during the rehabilitative phase to maintain flexibility and ensure that the maturing scar tissue does not permanently restrict movement.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Circumferential full-thickness burns to the chest create an inelastic eschar that restricts thoracic excursion. Knowledge of burn pathophysiology and respiratory mechanics is needed to identify life-threatening restrictive lung disease and the urgent need for a surgical escharotomy.

Choice A rationale

High pressure ventilator alarms occur when the ventilator meets resistance while delivering a breath. While this indicates a problem, it is a machine notification of the physiological restriction caused by the chest eschar and not the root observation.

Choice B rationale

Increasing peak pressures reflect decreased lung compliance or increased airway resistance. In this scenario, the pressures rise because the chest wall cannot expand, but the mechanical measurement is secondary to the physical assessment of chest movement.

Choice C rationale

Decreased thoracic expansion in a circumferential burn patient indicates the eschar is acting as a tourniquet. This prevents lung inflation, leading to rapid respiratory failure. This physical finding confirms the immediate need for an emergency escharotomy.

Choice D rationale

A SpO2 of 90 percent indicates hypoxemia, which is a significant clinical sign. However, it is a late manifestation of the underlying mechanical restriction. The priority is identifying the physical cause, which is the lack of expansion.

A. Performing activities of daily living (ADLs) without assistance. B. Recent weight loss of 27 lbs. C. Walking independently with the use of a cane. D. Right arm is badly bruised and discolored. E. Left hip is becoming more painful with movement. F. No new reports of shortness of breath or chest pain. G. Oxygen saturation (SpO2) of 95 H. Hip incision is healing with a visible hairline scar.

Correct Answer is ["A","C","F","G","H"]

Explanation

Evaluating post surgical and post pulmonary embolism recovery requires assessing functional mobility, respiratory stability, and wound healing. Knowledge of normal rehabilitation milestones and the resolution of thromboembolic symptoms is necessary to determine if the client is meeting expected outcomes.

Choice A rationale

Independent performance of activities of daily living indicates restored functional capacity and successful rehabilitation after surgery. It demonstrates that the client has regained sufficient strength and coordination to manage self care tasks without exhausting their cardiovascular reserves.

Choice B rationale

Unintentional weight loss of 27 lbs within six weeks is an abnormal finding that suggests underlying pathology, malnutrition, or chronic illness. It does not indicate improvement and instead necessitates further medical investigation to rule out complications.

Choice C rationale

Transitioning to independent walking with a cane shows progress in gait stability and weight bearing tolerance on the prosthetic joint. This movement away from more restrictive assistive devices like walkers is a positive indicator of recovery.

Choice D rationale

Significant bruising and discoloration are concerning signs, potentially indicating a bleeding disorder or complications from ongoing anticoagulation therapy. This finding represents a setback or a new problem rather than a sign of successful clinical improvement.

Choice E rationale

Increased pain with movement in the surgical area suggests potential complications such as infection, prosthesis loosening, or hip dislocation. Expected progress involves a steady decrease in pain levels as the surgical site heals over the weeks.

Choice F rationale

The absence of shortness of breath and chest pain indicates that the pulmonary embolism has resolved and gas exchange is stable. This respiratory comfort suggests that pulmonary perfusion has been restored and the lungs are healing.

Choice G rationale

An oxygen saturation of 95 is within the normal range of 95 to 100 percent. This indicates adequate arterial oxygenation and demonstrates that the client no longer requires supplemental oxygen to maintain systemic tissue perfusion after recovery.

Choice H rationale

A visible hairline scar without redness, swelling, or drainage confirms successful primary intention healing of the surgical incision. This indicates that the skin integrity is restored and the risk of localized or systemic infection is decreasing.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client in the rehabilitative phase of a burn injury has healed graft sites and is beginning mobility exercises. Which intervention is most important to minimize scarring and promote functional recovery?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing an intubated client with a deep partial-thickness burn to the right leg and a circumferential full-thickness burn to the chest. The nurse notes the SpO2 decreasing from 96 percent to 90 percent and high ventilator alarms. Which finding is most concerning to the nurse?

Correct Answer is C

Explanation

Correct Answer is ["A","C","F","G","H"]

Explanation

The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. The client has T 100.4 F, P 100, R 24, and BP 102/60. The client is complaining of severe pain. Which assessment data is most concerning to the nurse?

The partner of a client with terminal brain cancer asks the nurse about the client's prognosis. What is the most appropriate response by the nurse to address the partner's concerns?

A client presents with superficial burns and multiple intact blisters on the forearm. During dressing change, several blisters rupture and the underlying skin is exposed. Which action should the nurse take?

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

The nurse prepares to administer a 1,000 mg loading dose of phenytoin IV to a client with a subarachnoid hemorrhage. Which consideration is most important when administering this dose?

The nurse assesses an older adult client admitted with a new diagnosis of supratentorial glioma who has developed new symptoms. Which symptom is the most concerning to the nurse?

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

A client with cirrhosis and severe ascites is scheduled for a paracentesis. Post-procedure, the client develops signs of tachycardia, hypotension, and mild fever. Which conditions could cause these symptoms? Select all that apply.

A client in the rehabilitative phase of a burn injury has healed graft sites and is beginning mobility exercises.
Which intervention is most important to minimize scarring and promote functional recovery?