A nurse is caring for a 32-year-old male client in an outpatient rehabilitation setting.

A client has been recovering for 16 months from burns that affected 40% total body surface area. Which of the following complications should the nurse expect? (Select all that apply.)

Body image disorder

Post Traumatic Stress Disorder (PTSD)

Suicidal thoughts or depression

Electrolyte imbalance

Fluid volume deficit

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale:
Clients recovering from extensive burn injuries often experience body image disturbances due to visible scarring, contractures, and physical disfigurement. The emotional trauma associated with altered appearance affects self-esteem and social interactions. This client avoids looking at his scars and reports anxiety about his appearance, consistent with body image disorder. Burn survivors frequently need long-term psychological support and counseling to adjust to changes in physical identity and self-perception.

Choice B rationale:
The client shows clear signs of Post Traumatic Stress Disorder (PTSD)—such as nightmares, flashbacks, and emotional distress related to the fire. PTSD is common in burn survivors due to the traumatic nature of injury and hospitalization. The presence of hyperarousal symptoms and avoidance behaviors also aligns with PTSD diagnostic criteria in the DSM-5. Early identification and referral to mental health professionals are essential for managing PTSD in burn recovery.

Choice C rationale:
Suicidal ideation and depression are common psychological complications after severe burns, particularly with long rehabilitation periods, chronic pain, disfigurement, and loss of independence. This client expresses a low mood and occasional thoughts of self-harm, requiring immediate psychological intervention. Depression in burn clients can be linked to loss of function, changes in appearance, and feelings of hopelessness.

Choice D rationale:
Incorrect. Electrolyte imbalances are most critical during the acute phase (first 24–72 hours post-injury), especially in cases involving significant fluid shifts and tissue destruction. At 16 months post-injury, electrolyte levels usually stabilize unless other medical conditions exist. The client’s vitals and nutritional status are stable, with no signs of acute imbalance.

Choice E rationale:
Incorrect. Fluid volume deficit is an acute concern during the initial burn phase due to capillary leak and evaporative losses. At the rehabilitation stage, clients typically have normal fluid balance unless complications like infection or gastrointestinal issues arise. There is no clinical evidence of dehydration or hypotension in this client.

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Correct Answer is B

Explanation

Choice A rationale

Hand washing is highly effective against the common cold virus. The rhinovirus, responsible for most common colds, is primarily transmitted through direct contact with contaminated surfaces or respiratory droplets. Proper hand hygiene physically removes or inactivates the virus, significantly reducing its spread by disrupting the transmission pathway and minimizing self-inoculation from contaminated fomites.

Choice B rationale

The common cold virus can be highly communicable because individuals can shed the virus and transmit it before or during the onset of symptoms (the incubation and prodromal phases). This asymptomatic or mildly symptomatic shedding allows for widespread dissemination of the virus before the infected person is aware of their illness, contributing significantly to community transmission.

Choice C rationale

Mistaking common cold symptoms for seasonal allergies might delay appropriate hygiene measures and increase viral transmission. While symptoms can overlap, allergies are immune responses to allergens, whereas colds are viral infections. Incorrect self-diagnosis means individuals might not isolate or practice proper cough/sneeze etiquette, inadvertently spreading the virus to others in their environment.

Choice D rationale

The use of over-the-counter cold products does not inherently reduce immune resistance to the common cold virus. These medications primarily target symptom relief, such as decongestants or analgesics, and do not directly interfere with the body's immunological response or viral replication. Immune resistance remains dependent on the individual's overall health and prior exposure.

Correct Answer is ["6300"]

Explanation

Step 1 is to convert the client's weight from pounds to kilograms: 231 pounds ÷ 2.2 pounds/kg = 105 kg.

Step 2 is to calculate the total heparin units: 105 kg × 60 units/kg = 6300 units. The nurse will give 6300 units of heparin for the bolus.

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A nurse is caring for a 32-year-old male client in an outpatient rehabilitation setting. A client has been recovering for 16 months from burns that affected 40% total body surface area. Which of the following complications should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A clinic nurse is caring for a large number of clients diagnosed with the common cold. The nurse should recognize that which factor contributes to the high communicability of the common cold?

Correct Answer is B

Explanation

A nurse is caring for a client with acute coronary syndrome. The client is ordered weight-based heparin. The order reads, "Give Heparin bolus 60 units/kg IV push now.”. The nurse notes the client's weight is 231 pounds. How many units of heparin will the nurse give for the bolus?

Correct Answer is ["6300"]

Explanation

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A nurse is caring for a 32-year-old male client in an outpatient rehabilitation setting.

A client has been recovering for 16 months from burns that affected 40% total body surface area. Which of the following complications should the nurse expect? (Select all that apply.)