A nurse is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

"A piece of healthy skin will be removed from an unburned area and grafted over the burned area."

"This procedure involves placing the client into a Whirlpool tub and removing the dead tissue."

"Dead tissue will be non-surgically removed."

"Incisions will be made in the burnt tissues to improve circulation."

Answer and Explanation

The Correct Answer is D

A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not escharotomy.

B. "This procedure involves placing the client into a Whirlpool tub and removing the dead tissue.": This describes hydrotherapy or wound debridement.

C. "Dead tissue will be non-surgically removed.": Describes enzymatic or mechanical debridement.

D. "Incisions will be made in the burnt tissues to improve circulation.": Escharotomy relieves pressure caused by tight, burned skin (eschar) to restore blood flow and prevent compartment syndrome.

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Correct Answer is A

Explanation

A. Hyperkalemia: During the emergent phase, massive cell injury causes potassium to leak into the extracellular space, raising serum K+ levels.

B. Hypokalemia: More common later in the fluid resuscitation or diuretic phase.

C. Hypernatremia: Sodium is often lost into burned tissues or with fluid shifts; hyponatremia may be seen early.

D. Hypocalcemia: While possible, especially if blood products are given, hyperkalemia is more prominent early.

A. Fluid volume deficit B. Symptoms of Post traumatic C. Depression D. Electrolyte imbalances E. Body image disorder

Correct Answer is ["B","C","E"]

Explanation

A. Fluid volume deficit: This is an acute phase complication. After 12 months, the client is in the rehabilitation phase, and fluid balance is typically stabilized.

B. Symptoms of post-traumatic stress: PTSD is common after severe burn trauma, especially with long hospital stays or painful treatments.

C. Depression: Chronic physical and emotional stress, changes in appearance, and functional limitations contribute to depression.

D. Electrolyte imbalances: These are more likely during the acute and early recovery phase. At 12 months, electrolyte levels are usually normalized unless other complications exist.

E. Body image disorder: Disfigurement and scarring from severe burns often result in body image disturbances, which affect emotional well-being and social reintegration.

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A nurse is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with 45% total body surface area (TBSA) thermal burns. During the emergent, initial phases of burn shock the nurse should closely monitor for which electrolyte imbalance?

Correct Answer is A

Explanation

Patient presented for follow up of major burn injury. Exhibits A nurse is caring for a client recovering for 12 months from major burns that affected 60% total body surface area (TBSA). Which of the following complications should the nurse expect? (Select all that apply)

Correct Answer is ["B","C","E"]

Explanation

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