For a patient with partial-thickness burns covering the arms and chest, what is the priority assessment?
Capillary refill time.
Lung sounds and respiratory effort.
Pain score assessment.
Skin color and moisture.
The Correct Answer is B
Choice A rationale
While capillary refill time is an indicator of peripheral perfusion and should be within 2 to 3 seconds, it is not the highest priority for burns involving the chest. Peripheral circulation is important for assessing fluid resuscitation status and cardiac output, but it does not address immediate threats to life. In the hierarchy of trauma assessment, circulation follows the stabilization of the airway and the adequacy of the patient's breathing and ventilation.
Choice B rationale
Burns covering the chest carry a significant risk for inhalation injury and compromised chest wall expansion. The nurse must prioritize lung sounds and respiratory effort to detect stridor, wheezing, or decreased breath sounds which indicate airway edema or smoke inhalation. Inhalation of hot gases can cause rapid swelling of the glottis and subglottic structures. Ensuring a patent airway and adequate gas exchange is the most critical intervention in the emergent phase of burn care.
Choice C rationale
Pain assessment using a standardized score is necessary for patient comfort and to guide analgesic administration, particularly for partial-thickness burns which are extremely painful due to exposed nerve endings. However, pain is considered a secondary assessment compared to the respiratory system. While uncontrolled pain can increase metabolic demand and heart rate, it is not immediately life-threatening. The nurse addresses pain only after ensuring that the patient's airway and breathing are fully stabilized.
Choice D rationale
Assessing skin color and moisture helps determine the depth and severity of the burn, which is essential for calculating fluid requirements and planning wound care. Partial-thickness burns typically appear red, blistered, and moist. While this data is important for the overall treatment plan, it remains a lower priority than assessing for respiratory distress. Skin assessments are part of the secondary survey performed after the primary ABC assessment has been thoroughly completed and managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This response is therapeutic failure and scientifically inaccurate because many interventions can prevent the transition from subacute to chronic pain. Suggesting that the patient is helpless can lead to kinesiophobia and psychological distress, which are known risk factors for chronic pain development. Education on body mechanics and activity modification provides the patient with a sense of self-efficacy. Providing hope and actionable strategies is a core component of rehabilitative nursing care for back issues.
Choice B rationale
Prolonged bed rest and avoidance of all physical activity are contraindicated for subacute back pain. Evidence shows that excessive rest leads to muscle atrophy, joint stiffness, and a slower recovery process. Maintaining a level of activity within pain limits helps preserve the strength of the multifidus and transverse abdominis muscles. Nurses should encourage light walking and gentle stretching to maintain circulation to the spinal discs and prevent the secondary complications of a sedentary lifestyle.
Choice C rationale
Encouraging a patient to take medication early violates safe administration practices and ignores the root cause of the pain. This approach risks toxicity and does not address the mechanical issues contributing to the discomfort. It also fosters a reliance on pharmacological interventions rather than lifestyle modifications. The nurse should instead focus on non-pharmacological strategies and adhering to the prescribed dosing schedule to maintain steady therapeutic blood levels of analgesics like NSAIDs or acetaminophen.
Choice D rationale
Maintaining good posture and strengthening the core muscles are evidence-based strategies to stabilize the lumbar spine. A strong core acts as a natural brace, reducing the load on the vertebral discs and facet joints. Proper ergonomics during daily activities minimizes repetitive strain and prevents further injury. By focusing on these proactive measures, the patient can improve spinal alignment and muscle endurance, which significantly reduces the likelihood of the pain progressing into a long-term chronic condition.
Correct Answer is A
Explanation
Choice A rationale
On the Braden Scale, a total score of 10 to 12 represents a high risk for the development of pressure injuries. This scale assesses six subscales including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A lower score indicates a higher risk. At this level, aggressive preventive interventions are required immediately, such as frequent repositioning every two hours, using pressure-redistributing surfaces, and optimizing nutritional intake to protect the integrity of the skin and underlying tissues.
Choice B rationale
A Braden Scale score ranging from 15 to 18 is categorized as a mild risk for pressure injury development. While this score still necessitates some preventive measures, such as turning schedules and moisture management, it does not represent the high-risk category that requires the most intensive level of intervention. The nurse should still monitor the patient closely, but the urgency is lower than for a patient scoring in the 10 to 12 range or below.
Choice C rationale
Scores between 19 and 23 on the Braden Scale indicate that the patient is at a very low risk or is generally not at risk for developing pressure injuries. Patients in this range typically have good mobility, adequate nutrition, and intact sensory perception. While routine skin care and assessment remain part of standard nursing practice, specialized pressure-relief protocols are generally not indicated for this group unless their clinical status changes significantly or their mobility becomes suddenly impaired.
Choice D rationale
A score of 24 to 30 is not possible on the standard Braden Scale, as the maximum score is 23. The scale evaluates six categories with most having a maximum of 4 points and one having a maximum of 3 points. Therefore, any score above 23 is mathematically impossible. When using this assessment tool, nurses must be familiar with the correct scoring range to accurately identify patient risk and implement the appropriate evidence-based interventions for skin protection.
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