A client is brought to the emergency department with burns over 40% of the body from apartment fire. Which assessment should take priority?
Percent of body surface burned
Respiratory status
Review of chronic illnesses
Burn depth
The Correct Answer is B
A. Percent of body surface burned:
Important for guiding fluid resuscitation, but airway and breathing always take priority in the ABCs.
B. Respiratory status:
Inhalation injury is a life-threatening complication in fire-related burns. Assess for stridor, soot in nares/mouth, and signs of respiratory distress first.
C. Review of chronic illnesses:
Relevant for overall care planning, but not an initial priority in the emergency phase.
D. Burn depth:
Guides long-term care but is secondary to airway and breathing in the acute setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased metabolic rate:
Burns cause an increase, not decrease, in metabolic rate due to the hypermetabolic state post-injury.
B. Increased capillary permeability:
This is a hallmark of burn injuries. Damaged capillaries leak fluid into interstitial spaces, leading to fluid and electrolyte imbalance.
C. Normal electrolyte levels:
Electrolyte levels are often abnormal in burn patients due to fluid shifts and tissue damage.
D. Excessive fluid intake:
Overhydration can be harmful, but it is not a typical cause of the initial fluid imbalance seen in burns.
Correct Answer is []
Explanation
Most Likely Condition:
Herpes zoster (Shingles): The client presents with a painful, burning, unilateral rash in a dermatomal distribution with grouped vesicles on an erythematous base — classic for herpes zoster (shingles). The shoulder x-ray is normal, ruling out musculoskeletal causes.
Actions to Take:
Anticipate administering an antiviral medication: Antiviral medications like acyclovir, valacyclovir, or famciclovir reduce the severity and duration of shingles if started early.
Request a prescription analgesic medication: Shingles is often extremely painful. Ibuprofen was ineffective, so stronger analgesics are likely needed.
Parameters to Monitor:
Pain: Pain monitoring assesses the effectiveness of analgesic and antiviral treatment.
Post-herpetic neuralgia (nerves): Monitoring for lingering nerve pain is crucial, as shingles can lead to long-term nerve damage.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.