An adult male patient enters the emergency department with full- and partial-thickness burns on the entire right leg, front of the right arm, and one half of the front torso. The nurse, using the rule of nines assesses the burn as

Answer and Explanation

The Correct Answer is A

The "Rule of Nines" is used to estimate the total body surface area (TBSA) affected by burns in adults.

Entire right leg: 9% (front) + 9% (back) = 18%
Front of the right arm: The entire arm is 9%, so the front half would be approximately 4.5%.
One half of the front torso: The entire front torso (chest and abdomen) is 18%. One half of the front torso is 18% / 2 = 9%.
Adding these percentages:

18% (right leg) + 4.5% (front right arm) + 9% (half front torso) = 31.5%.

This approximated by 32%.

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Correct Answer is ["A","B"]

Explanation

A. Bradypnea: Bradypnea, or slow breathing, is a late sign of increased ICP. As pressure rises, the brainstem becomes compressed, leading to respiratory irregularities such as bradypnea. This can indicate a severe increase in ICP and requires immediate attention.

B. Cushing's triad: Cushing's triad, which consists of hypertension, bradycardia, and irregular respirations is a classic late sign of increased ICP. It occurs due to pressure on the brainstem and is a sign of impending brain herniation, which is a medical emergency.

C. Hypertension: Hypertension can be seen in the early stages of ICP due to compensatory mechanisms aimed at maintaining cerebral perfusion. However, it is not typically a late sign. The late sign would be an abnormal change in blood pressure patterns, as seen in Cushing's triad.

D. Mental status changes slightly: Slight mental status changes are an early sign of increased ICP, not a late one. As ICP rises, more pronounced changes in consciousness and cognition occur, such as confusion, stupor, or coma, signaling a more advanced stage of ICP.

E. Slurred speech: Slurred speech can be an early or moderate sign of ICP, depending on the location and severity of the pressure. However, it is not considered a late sign. More significant neurological impairments occur as ICP continues to increase.

A. Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal B. Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing. C. Choose foods that are high in protein, such as meat, eggs and beans. These help the burns to heal D. It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will provide energy and help with healing faster

Correct Answer is C

Explanation

A. Saturated fats do not directly interfere with wound healing. While excessive intake of unhealthy fats should be minimized for overall health, fats themselves are not the primary focus when promoting wound healing in burn patients.

B. Fiber is important for digestive health but does not directly affect wound healing in burn patients. Protein and calories are more important for supporting tissue repair and overall healing.

C. Protein is essential for tissue repair, wound healing, and immune function, making it a priority nutrient for burn patients. High-protein foods support the increased metabolic demands of healing and help rebuild damaged tissues.

D. While carbohydrates are important for energy, protein plays a more significant role in wound healing. A balance of carbohydrates and protein is ideal, but protein is the primary nutrient needed for tissue repair in burn patients.

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An adult male patient enters the emergency department with full- and partial-thickness burns on the entire right leg, front of the right arm, and one half of the front torso. The nurse, using the rule of nines assesses the burn as

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which two of the following findings should the nurse identify as a late sign of ICP? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

The nurse is assisting a burn-injured patient to select foods that promote wound healing. Which statement indicates the knowledge of the nurse regarding nutritional goals for this patient?

Correct Answer is C

Explanation

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An adult male patient enters the emergency department with full- and partial-thickness burns on the entire right leg, front of the right arm, and one half of the front torso. The nurse, using the rule of nines assesses the burn as