A nurse is developing a plan of care for a client who is admitted with major burns requiring debridement. Which of the following interventions demonstrates the provision of emotional support?

Rotate nursing staff so the client can have varied interactions.

Talk with the client during wound care.

Assign assistive support to keep the client's room neat and clean.

Keep family members aware of the client's condition.

Answer and Explanation

The Correct Answer is B

A. Rotate nursing staff so the client can have varied interactions: Frequent changes in caregivers may reduce continuity and trust, which are essential in emotionally supporting clients with traumatic injuries like burns.

B. Talk with the client during wound care: Engaging the client during painful and emotionally distressing procedures provides reassurance, reduces anxiety, and builds therapeutic rapport which are key components of emotional support.

C. Assign assistive support to keep the client's room neat and clean: Maintaining a clean environment is important for infection control and comfort, but it does not directly address the client’s emotional needs.

D. Keep family members aware of the client's condition: Keeping the family informed is important, but emotional support is most effective when directed to the client through therapeutic communication and presence.

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Correct Answer is ["A","B","E","F","G","H"]

Explanation

Cardiac:

Electrolyte imbalances
Increased frequency of PVCs

Respiratory:

Stridor-like respirations
Oral or nasal soot

Renal:

Elevated serum myoglobin
UOP less than 30 mL/hour

Rationale:

Cardiac:

Electrolyte imbalances: The potassium is elevated at 5.8 mEq/L, which contributes to dysrhythmias like PVCs.
Increased frequency of PVCs: Frequent PVCs indicate cardiac irritability, often related to electrolyte disturbances and hypovolemia in burns.
Bradycardia is not supported by the chart; heart rate is elevated at 130 bpm indicating tachycardia.
Respiratory:
- Stridor-like respirations: Indicates upper airway obstruction, a critical sign of inhalation injury.
- Oral or nasal soot: Suggests potential inhalation of smoke or toxins, a major risk factor for respiratory compromise.
- Pox 95% on 4L NC is low-normal but not a priority finding compared to active signs of airway injury.
Renal:
- Elevated serum myoglobin: Indicates muscle breakdown (rhabdomyolysis), which can obstruct renal tubules and cause acute kidney injury.
- UOP less than 30 mL/hour: The insertion of a Foley with only 25 mL of dark urine suggests decreased renal perfusion and myoglobinuria.
- UOP greater than 100 mL/hour is not indicated in the assessment.

A. Urinary output 25 mL/hr B. Difficulty swallowing secretions C. Heart rate 122/min D. Pain of 6 on a scale of 0 to 10

Correct Answer is B

Explanation

A. Urinary output 25 mL/hr: This is slightly below the expected minimum of 30 mL/hr but can often be corrected with fluid resuscitation. It is not the most urgent concern in the presence of airway risk.

B. Difficulty swallowing secretions: Burns to the face, ears, and eyelids raise suspicion of inhalation injury. Difficulty managing secretions suggests airway edema and impending obstruction, making it the most critical and time-sensitive finding.

C. Heart rate 122/min: Tachycardia is common in burn injuries due to pain, stress, and fluid loss. While it requires monitoring, it does not take precedence over potential airway compromise.

D. Pain of 6 on a scale of 0 to 10: Pain of 6 on a scale of 0 to 10 indicates significant pain that requires management in burn patients. However, ensuring a patent airway and adequate breathing takes precedence over pain control in the initial assessment, especially with burns to the face and neck.

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System Assessment	Priority findings
Cardiac	Electrolyte imbalances Increased Frequency of PVCS Bradycardia
Respiratory	Pox reading of 95% on 4 liter NC stridor like respirations oral or nasal soot
Renal	Elevated serum myoglobin UOP less than 30ml/hour UOP greater than 100mL/hour

A nurse is developing a plan of care for a client who is admitted with major burns requiring debridement. Which of the following interventions demonstrates the provision of emotional support?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","E","F","G","H"]

Explanation

A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?

Correct Answer is B

Explanation

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