A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? (Select all that apply.)
Decreased plasma volume
Diuresis
Hypermagnesemia
Capillary leak
Loss of protein
Correct Answer : A,D,E
A. Decreased plasma volume: Burn injuries cause a significant inflammatory response, leading to fluid shifts from the intravascular space to the interstitial space. This results in hypovolemia and decreased plasma volume, especially during the acute phase of burns.
B. Diuresis: Diuresis typically occurs after fluid resuscitation and stabilization of the client (in the later phase of burn recovery). In the initial phase, oliguria is more common due to hypovolemia and reduced renal perfusion.
C. Hypermagnesemia: Hypermagnesemia is not typically associated with burn injuries. Instead, clients with burns often experience hypomagnesemia due to fluid shifts, protein loss, and increased renal losses.
D. Capillary leak: Burn injuries lead to a systemic inflammatory response, causing capillary leak syndrome. This increases vascular permeability, allowing fluid, electrolytes, and proteins to leak into the interstitial spaces, contributing to edema and hypovolemia.
E. Loss of protein: Proteins are lost through damaged capillaries and open burn wounds, contributing to decreased oncotic pressure, edema, and a need for aggressive nutritional support to promote healing and recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Superficial infections are caused by fungus.
While fungal infections can indeed cause superficial skin infections like tinea (ringworm) or candidiasis, they are not the common factor for the etiology and pathophysiology of folliculitis, furuncles, and carbuncles. These conditions primarily involve bacterial infections of the hair follicles, typically caused by Staphylococcus aureus bacteria.
B. Parasites get underneath the skin.
Parasitic infections can cause various skin conditions, but they are not the common factor for folliculitis, furuncles, and carbuncles. These conditions are specifically related to bacterial infections of the hair follicles rather than parasitic infestations.
C. Hair follicles are infected or inflamed.
This is the correct choice and the common factor for folliculitis, furuncles, and carbuncles. All three conditions involve the infection or inflammation of hair follicles, primarily due to Staphylococcus aureus bacteria. Folliculitis is the inflammation of one or more hair follicles, furuncles are deeper infections involving the hair follicle and surrounding tissue, and carbuncles are clusters of interconnected furuncles with deeper tissue involvement.
D. There is an allergic response to an allergen.
An allergic response to an allergen does not play a role in the etiology and pathophysiology of folliculitis, furuncles, and carbuncles. These conditions are primarily infectious in nature, involving bacterial colonization and subsequent inflammation of the hair follicles rather than an allergic response.
Correct Answer is B
Explanation
A. Infection: While infection can certainly delay wound healing and contribute to the development of chronic wounds, it is more of a local factor rather than a systemic cause. Infections can hinder the normal healing process and lead to tissue damage, inflammation, and prolonged wound healing.
B. Malnutrition
A chronic wound is a wound that fails to progress through the normal stages of healing in an orderly and timely manner. Systemic factors can significantly impact wound healing, and malnutrition is one such systemic cause. Malnutrition, which refers to an inadequate intake or absorption of nutrients essential for healing, can impair the body's ability to repair tissues, fight infection, and generate new cells.
C. Continued pressure: Prolonged pressure, such as that experienced in pressure ulcers, can lead to tissue ischemia (lack of blood flow) and tissue necrosis, resulting in chronic wounds. However, this is considered a local factor related to the specific site of the wound and pressure-related damage.
D. Venous insufficiency: Venous insufficiency can cause chronic wounds, particularly venous ulcers, due to impaired venous return leading to increased pressure in the veins of the lower extremities. This pressure can result in tissue damage and poor wound healing. While venous insufficiency is a systemic condition, it primarily affects specific areas of the body (such as the lower legs) and is more directly related to the development of localized chronic wounds in those areas.
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