A female client sustains a deep partial-thickness burn covering more than 40% of her body. Which physiological response should the nurse anticipate during the acute phase of burn injury?

Increased capillary permeability leading to plasma leakage into interstitial tissues.

Hypervolemia due to excessive fluid retention.

Decreased inflammatory response and delayed wound healing.

Reduced risk of infection because of intact skin barriers.

Answer and Explanation

The Correct Answer is A

A. During the acute phase of a severe burn, the body initiates a systemic inflammatory response. Burn injury causes increased capillary permeability, allowing plasma, electrolytes, and proteins to leak into the interstitial space. This leads to edema, hypovolemia, and hemoconcentration, which are hallmark signs of the burn shock phase. Early recognition and fluid resuscitation are critical to prevent organ hypoperfusion and shock.

B. Initially, burn injury leads to hypovolemia, not hypervolemia, due to fluid shifts out of the vascular space. Without proper fluid replacement, the client is at high risk for shock rather than fluid overload.

C. The inflammatory response is actually heightened after a burn, not decreased. This hyperactive response contributes to tissue edema, capillary leakage, and systemic effects. While wound healing may be delayed due to tissue damage, the acute phase is dominated by inflammation, not suppression.

D. The risk of infection is increased, not reduced, after a burn because the skin barrier is destroyed. Burn wounds expose underlying tissues to pathogens, making infection a major concern during the acute phase.

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Correct Answer is D

Explanation

A. These devices are used to prevent deep vein thrombosis (DVT) in immobile clients. While important for stroke patients, they are not an immediate priority in the initial management of acute neurological deficits.

B. Proper limb positioning helps prevent contractures and edema, but it is not critical in the acute phase where neurological assessment and preventing increased intracranial pressure (ICP) take priority.

C. This information is important to evaluate eligibility for thrombolytic therapy, but the immediate safety measure is to manage the client’s positioning to reduce ICP and optimize cerebral perfusion while awaiting imaging. History-taking should be done quickly, but positioning is the priority intervention in the acute phase.

D. This intervention promotes venous drainage from the brain, reduces intracranial pressure, optimizes cerebral perfusion pressure, and prevents neck flexion or rotation that could compromise blood flow to the brain.

A. Restrict daily fluid intake to 1500 mL. B. Weigh client every morning. C. Maintain accurate intake and output. D. Administer prescribed diuretic.

Correct Answer is D

Explanation

A. Restricting daily fluid intake is a common intervention for clients with fluid overload to help prevent further accumulation. While it can help manage the condition over time, it does not provide immediate relief from the client’s acute symptoms such as pulmonary congestion or shortness of breath. Relying solely on fluid restriction could allow the client’s condition to worsen, increasing the risk of respiratory compromise and cardiovascular strain.

B. Weighing the client every morning is an essential tool for monitoring fluid status and detecting trends over time. A sudden weight gain, such as 2 pounds in one day, is a key indicator of fluid retention. However, this action is primarily for assessment and does not actively treat the current overload.

C. Maintaining accurate intake and output is critical for assessing fluid balance and monitoring the effectiveness of interventions such as diuretics or fluid restriction. Although it provides valuable information for ongoing care planning, it does not reduce the fluid overload causing the client’s immediate symptoms.

D. Administering the prescribed diuretic is the priority intervention in this scenario. The client demonstrates clinical signs of fluid volume excess, including bounding peripheral pulses indicating increased circulating blood volume, significant weight gain reflecting fluid retention, pitting ankle edema showing interstitial fluid accumulation, and moist crackles bilaterally suggesting pulmonary congestion. The diuretic promotes renal excretion of excess fluid and sodium, reducing intravascular and interstitial volume. This intervention directly alleviates symptoms, decreases the risk of pulmonary edema, lowers cardiac workload, and prevents further complications such as heart failure exacerbation. It is considered the highest priority action according to the ABC (Airway, Breathing, Circulation) framework, because untreated fluid overload can compromise respiratory function and lead to life-threatening complications.

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A female client sustains a deep partial-thickness burn covering more than 40% of her body. Which physiological response should the nurse anticipate during the acute phase of burn injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is D

Explanation

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