A patient has suffered a deep, full thickness burn after a car fire.
The nurse understands that burns can cause more than just body tissue damage.
Which issues are the main areas of focus when caring for patients with burns? Select all three that apply.
Loss of temperature regulation.
Sensory malfunction.
Major fluid shift.
Impaired balance.
Correct Answer : A,C
Choice A rationale
Burns destroy the protective layers of the skin, including the epidermis and dermis, which are essential for maintaining body temperature. This damage leads to a significant loss of heat through evaporation and impaired vasoregulation, making the patient highly susceptible to hypothermia. This is a critical physiological disruption that requires meticulous thermoregulatory support.
Choice B rationale
Sensory malfunction is not a primary concern with full thickness burns. Full thickness burns, also known as third-degree burns, destroy nerve endings in the affected area, leading to a loss of sensation, not a malfunction. The main issues are systemic, such as fluid shifts and loss of thermoregulation, which are more immediately life-threatening.
Choice C rationale
A major fluid shift is a hallmark of severe burns. The immense tissue damage causes increased capillary permeability, leading to a massive leakage of plasma and proteins from the intravascular space into the interstitial space. This results in hypovolemia, edema, and a significant risk of burn shock, which requires aggressive fluid resuscitation to prevent.
Choice D rationale
Impaired balance is not a typical or primary complication of burns. While large burns can affect mobility and cause generalized weakness, balance issues are not a direct physiological consequence of the burn injury itself. The focus of burn care is on managing the more critical and systemic complications, such as hypovolemia, infection, and thermoregulatory dysfunction. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Eczema, or atopic dermatitis, is a chronic inflammatory skin condition characterized by itchy, red, and swollen skin. While it can be patchy, it typically presents with weeping, crusting, and scaling, but not the thick, silvery scales characteristic of the described rash. Eczema often occurs in skin folds and flexural surfaces, distinguishing it from the patient's presentation.
Choice B rationale
Psoriasis is a chronic autoimmune condition causing an accelerated turnover of skin cells. This rapid proliferation leads to the formation of thick, red patches covered with characteristic silvery scales. The typical locations are the elbows, knees, and scalp, which perfectly matches the patient's presentation, making this the most likely diagnosis.
Choice C rationale
Scabies is a contagious infestation of the skin by the human itch mite. It presents as an intensely itchy rash, often with small, raised red bumps and burrows, typically found in skin folds, between fingers, and on the wrists. It does not produce the thick, silvery scales seen in the patient's rash, making this choice incorrect.
Choice D rationale
Seborrheic dermatitis is a common skin condition that mainly affects the scalp, causing flaky scales and red skin, and is commonly known as dandruff. While it can occur in other oily areas of the body, it does not typically present with the thick, silvery scales on the elbows and knees that are highly indicative of psoriasis. *.
Correct Answer is A
Explanation
Choice A rationale
Anorexia nervosa is a psychiatric eating disorder characterized by a low body mass index due to a distorted body image and an intense fear of gaining weight. While it can lead to various health complications, it is not a direct or established risk factor for the formation of a pulmonary embolism. The primary risk factors are related to Virchow's triad: venous stasis, hypercoagulability, and endothelial injury. Anorexia does not directly cause any of these conditions.
Choice B rationale
Immobility or prolonged travel, such as sitting for more than four hours, significantly increases the risk of deep vein thrombosis (DVT), a precursor to pulmonary embolism. Prolonged inactivity leads to venous stasis, where blood pools in the lower extremities. This sluggish blood flow promotes the aggregation of platelets and clotting factors, increasing the likelihood of thrombus formation in the deep veins of the legs.
Choice C rationale
Pregnancy is a significant risk factor for pulmonary embolism due to several physiological changes. The gravid uterus compresses the inferior vena cava, causing venous stasis in the lower extremities. Additionally, pregnancy induces a hypercoagulable state to prevent excessive bleeding during childbirth. The combination of venous stasis and hypercoagulability significantly elevates the risk of DVT and subsequent PE.
Choice D rationale
Central venous catheters are a well-established risk factor for both DVT and pulmonary embolism. The presence of a foreign body in a large vein, such as the subclavian or jugular vein, causes localized endothelial injury. This damage to the vascular lining triggers the coagulation cascade, promoting the formation of a thrombus directly on or around the catheter tip. The thrombus can then embolize to the lungs.
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