A nurse is caring for a client with full thickness burns on 40 percent of their body. What assessment findings does the nurse expect with this type of injury? (Select all that apply)

Hypovolemic shock

Hypertension

Fluid volume deficit

Increased pulse rate

Decreased cardiac output

Answer and Explanation

Correct Answer : A,C,D,E

Choice A reason: Full thickness burns involve the destruction of all skin layers and underlying structures, leading to a massive inflammatory response and "capillary leak" syndrome. This loss of intravascular fluid into the interstitial space causes a profound decrease in circulating volume, known as burn-induced hypovolemic shock.

Choice B reason: Hypertension is not an expected finding in the acute phase of a major burn injury. The primary hemodynamic challenge is hypotension due to fluid loss and systemic vasodilation. Hypertension would only be seen much later in the recovery phase or as a result of a pre-existing condition.

Choice C reason: Fluid volume deficit is a certainty in large percentage burns. The loss of the skin barrier leads to massive evaporative water loss, while the systemic inflammatory response causes fluid to shift from the vascular compartment into the tissues, resulting in severe dehydration and intravascular depletion.

Choice D reason: An increased pulse rate, or tachycardia, is a compensatory mechanism by the sympathetic nervous system. In response to a decreased stroke volume from fluid loss, the heart beats faster to attempt to maintain adequate cardiac output and perfusion to vital organs during the shock state.

Choice E reason: Decreased cardiac output occurs during the initial "eb b" phase of burn shock. The combination of reduced intravascular volume (low preload) and the release of myocardial depressant factors during the systemic inflammatory response leads to a significant reduction in the heart's overall pumping efficiency.

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Correct Answer is B

Explanation

Choice A reason: Multiple organ dysfunction syndrome carries an extremely high mortality rate, often exceeding 70% to 90% as the number of failing organ systems increases. Providing a "good" prognosis is clinically inaccurate and offers false hope, which can hinder the family’s ability to make informed medical decisions.

Choice B reason: MODS represents the terminal stage of the shock continuum where homeostasis cannot be maintained. The nursing priority shifts toward holistic support, ensuring the family understands the gravity of the situation and facilitating discussions regarding goals of care, palliative measures, and potentially the withdrawal of life support.

Choice C reason: MODS is an acute, critical condition characterized by rapid physiological decline. It is not a chronic state; patients do not "live for years" with multiple failing organs. The clinical course is typically measured in days or weeks, requiring intensive, minute-to-minute medical and nursing interventions.

Choice D reason: While organ donation is a valid consideration in end-of-life care, it is generally not the primary focus of the nursing plan of care for a MODS patient. Furthermore, the systemic inflammatory process and underlying infection that usually trigger MODS often render the patient’s organs unsuitable for transplantation.

A. A client three hours post-myocardial infarction B. A client with trauma related blood loss C. A client with a tension pneumothorax D. A client with positive blood cultures

Correct Answer is A

Explanation

Choice A reason: Cardiogenic shock occurs when the heart’s muscular wall fails to pump effectively. A myocardial infarction (MI) causes necrosis of the cardiac tissue; if more than 40% of the left ventricle is damaged, the heart cannot maintain adequate cardiac output, leading directly to cardiogenic shock.

Choice B reason: A client with trauma-related blood loss is at risk for hypovolemic shock. This type of shock is caused by a lack of intravascular volume rather than a primary failure of the heart muscle itself, distinguishing it from the pump-failure mechanism of cardiogenic shock.

Choice C reason: A tension pneumothorax causes obstructive shock. The high pressure in the thoracic cavity shifts the mediastinum and compresses the great vessels (superior and inferior vena cava), physically preventing blood from returning to the heart, which is different from a primary muscular failure.

Choice D reason: A client with positive blood cultures is at risk for septic shock. This is a form of distributive shock caused by systemic vasodilation and increased capillary permeability in response to an overwhelming infection, rather than an initial failure of the cardiac pump.

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A nurse is caring for a client with full thickness burns on 40 percent of their body. What assessment findings does the nurse expect with this type of injury? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is suffering from multiple organ dysfunction syndrome (MODS). What does the nursing plan of care focus on?

Correct Answer is B

Explanation

Which client is at the greatest risk of developing cardiogenic shock?

Correct Answer is A

Explanation

The nurse is preparing to perform a sterile dressing change on a client who obtained full-thickness burns on the right leg one week ago. Which intervention would the nurse implement first?

A nurse teaches the unlicensed assistive personnel (UAP) about providing hygiene for a client in traction. Which statement would the nurse include as part of the teaching about this client's care?

The nurse is caring for a client with suspected sepsis. What actions will the nurse take within one hour of the client being identified as being at risk for sepsis? (Select all that apply)

A client diagnosed with Multiple Organ Dysfunction Syndrome (MODS) has been started on vasopressin. What assessment finding requires the nurse to communicate with the primary health care provider immediately?

Which clinical manifestation indicates worsening in the condition of a client in the refractory phase of shock?

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A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates additional instruction is needed?

A client in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which assessment finding requires immediate nursing action?