A nurse is caring for a client with an electrical burn.
The client states that since the wound on the skin is small, the burn must not be too bad.
Which of the following is the best response by the nurse?
Electrical burns usually cause much more skin damage than what can be seen on your skin.
Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
Electrical burns commonly cause reddened/purplish skin without blistering.
Electrical burns typically are minor.
The Correct Answer is B
Choice A rationale
While it’s true that electrical burns can cause more skin damage than what can be seen on the skin, this statement does not fully address the client’s misconception about the severity of their burn.
Choice B rationale
This is the best response because it directly addresses the client’s misconception and provides accurate information. Electrical burns can indeed have small amounts of skin damage but cause more extensive damage beneath the skin. This is because the electrical current can pass through the body and damage internal tissues and organs, even if the visible wound on the skin is small.
Choice C rationale
While electrical burns can cause reddened or purplish skin, they do not typically cause blistering. Furthermore, this statement does not address the client’s misconception about the severity of their burn.
Choice D rationale
This statement is incorrect. Electrical burns are not typically minor. They can cause serious internal injuries and complications, even if the visible wound on the skin is small.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This statement accurately explains what adhesions are. Adhesions are areas of scar tissue that form between organs or tissues in the abdomen. They often form after surgery and can cause some of these loops to stick together, resulting in abdominal pain and occasionally obstruction (blockages) in the gut. In the context of a small bowel obstruction, adhesions can cause the intestines to twist or kink, similar to how a garden hose can become kinked.
Choice B rationale
While this statement may be intended to reassure the client, it does not provide the client with the information they are seeking about what adhesions are and how they are causing the blockage.
Choice C rationale
Offering to provide reading materials about the procedure does not directly answer the client’s question about what adhesions are. It may also be overwhelming for the client who is already anxious and preparing for emergency surgery.
Choice D rationale
This statement minimizes the client’s concerns and does not provide the necessary information about what adhesions are and how they are causing the blockage.
Correct Answer is A
Explanation
Choice A rationale
During the fluid resuscitation phase of burn management, the primary goal is to restore circulating volume and preserve vital organ and tissue perfusion. One of the most effective methods for assessing the results of fluid resuscitation is monitoring urine output. A urine output greater than 0.5 mL/kg/hr is generally considered an indicator of adequate fluid resuscitation.
Choice B rationale
While clear bilateral breath sounds are an important part of overall patient assessment, they are not the best method for assessing the results of fluid resuscitation in burn management.
Choice C rationale
Serum hemoglobin is not the best indicator for assessing the results of fluid resuscitation in burn management. While it can provide information about the patient’s overall health and blood volume, it does not directly reflect the adequacy of fluid resuscitation.
Choice D rationale
A heart rate of 122/min could indicate a response to pain, anxiety, or inadequate fluid resuscitation. However, it is not the best method for assessing the results of fluid resuscitation in burn management.
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