A nurse is caring for a client who has severe burns.

Exhibits
Which of the following actions should the nurse take when caring for a client with severe burns?
Select all that apply.

Cool the burn with ice water.

Administer opioid analgesics.

Administer systemic antibiotics.

Administer benzodiazepines for anxiety management.

Lay the head of the bed flat.

Answer and Explanation

Correct Answer : B,D

A. Cool the burn with ice water: Cooling with ice water is contraindicated as it can cause vasoconstriction and worsen tissue damage. Cool saline or tepid water is preferred for immediate care.

B. Administer opioid analgesics: Severe burns are excruciatingly painful, and opioid analgesics are appropriate for managing the pain.

C. Administer systemic antibiotics: Systemic antibiotics are not routinely administered unless there are signs of infection or sepsis.

D. Administer benzodiazepines for anxiety management: Anxiety can exacerbate the client’s distress, and benzodiazepines are effective in reducing anxiety.

E. Lay the head of the bed flat: This is inappropriate; the client’s airway must remain patent, and raising the head of the bed can help reduce respiratory distress.

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

Explanation

A. Administer supplemental oxygen to the client: Oxygen saturation is low (86%), and supplemental oxygen is necessary to address hypoxia.

B. Place a tongue depressor in the client’s mouth: Inserting objects into the mouth can cause injury and is contraindicated during a seizure.

C. Turn the client to the side: Turning the client reduces the risk of aspiration by allowing secretions or emesis to drain.

D. Restrain the client: Restraining the client may cause harm and is not recommended during seizure activity.

E. Time the duration of the seizure: Documenting seizure duration helps determine its severity and guides treatment decisions.

A. Increased blood supply and edema to the area of injury B. Damage to brain tissue from decreased pressure shock waves C. Disruption of cellular function and blood vessel damage D. Increased synaptic connections from pressure

Correct Answer is C

Explanation

A. Increased blood supply and edema to the area of injury: While edema occurs, increased blood supply is not typically a feature of TBI; rather, blood flow may be impaired.

B. Damage to brain tissue from decreased pressure shock waves: Increased intracranial pressure (not decreased) is a more likely outcome.

C. Disruption of cellular function and blood vessel damage: TBIs cause mechanical disruption to brain cells and vasculature, leading to secondary effects such as swelling, ischemia, and cellular dysfunction.

D. Increased synaptic connections from pressure: Increased pressure does not enhance synaptic connections; instead, it disrupts neural activity.

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A nurse is caring for a client who has severe burns. Exhibits Which of the following actions should the nurse take when caring for a client with severe burns? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a seizure disorder. Exhibits A nurse is caring for a client who has a seizure disorder. (Select all that apply.)

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

Explanation

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following should the nurse understand is a possible consequence of a TBI?

Correct Answer is C

Explanation

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

A nurse is caring for a client who had a traumatic brain injury (TBI). Which of the following manifestations indicate a mild TBI?

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A nurse in an emergency department (ED) is admitting a client. Exhibits Select the 3 findings that require immediate follow-up.

A nurse is caring for a client who has severe burns.

Exhibits
Which of the following actions should the nurse take when caring for a client with severe burns?
Select all that apply.