Priority nursing diagnoses for burns include: (Select All That Apply)

Adequate Tissue Perfusion

Risk for infection

Impaired Gas Exchange

Acute Pain

Fluid Volume Deficit

Answer and Explanation

Correct Answer : B,C,D,E

A. Adequate Tissue Perfusion
While this important in burn management, it is not typically classified as a priority nursing diagnosis in the early stages of treatment.

B. Risk for infection
Burned skin is a lost barrier to pathogens, increasing infection risk.

C. Impaired Gas Exchange
Especially in cases of inhalation injury, airway swelling or carbon monoxide exposure can impair gas exchange.

D. Acute Pain
Burns cause significant pain that requires management for comfort and healing.

E. Fluid Volume Deficit
Burns result in fluid shifts and capillary leakage, leading to hypovolemia.

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Correct Answer is D

Explanation

A. Reports of joint discomfort:
Not typically associated with contact dermatitis.

B. Elevated temperature:
Systemic symptoms like fever are not common in localized contact dermatitis.

C. Denial of pruritus:
Itching (pruritus) is a hallmark symptom of contact dermatitis.

D. Reports of exposure to a skin irritant:
Contact dermatitis occurs following direct contact with an irritant or allergen.

A. "I should apply a sunscreen with an SPF of 30.” B. "Sunscreen does not need to be applied on a cloudy day." C. "A sunscreen is a better choice for my toddler than a sunblock." D. "I can expose my 3-month-old infant to the sun if I apply sunscreen."

Correct Answer is A

Explanation

A. "I should apply a sunscreen with an SPF of 30.”
SPF 30 is the recommended minimum for effective sun protection. It blocks about 97% of UVB rays.

B. "Sunscreen does not need to be applied on a cloudy day."
Up to 80% of UV rays can penetrate clouds, so sunscreen is still necessary on cloudy days.

C. "A sunscreen is a better choice for my toddler than a sunblock."
Sunblock (physical blockers like zinc oxide) are often safer and more effective for young children than chemical sunscreens.

D. "I can expose my 3-month-old infant to the sun if I apply sunscreen."
Sunscreen is not recommended for infants under 6 months. They should be kept out of direct sunlight entirely.

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Priority nursing diagnoses for burns include: (Select All That Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse at a community center is assisting with a presentation about sun protection to a group of residents. Which of the following responses by the residents indicates an understanding of the teaching?

Correct Answer is A

Explanation

The nurse is explaining to a family the benefit of a patient-controlled analgesia pump. Which of the following is an appropriate use of Dilaudid PCA for burn patients?

A nurse is collecting data on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority?

The nurse in a high school clinic is aware of an unusually high incidences of cold sores among the student population. Which information from the nurse will be the most helpful in controlling the spread of the causative virus, HSV-1?

While collecting data on a patient, the nurse observes that the patient's facial skin is reddened and is covered with greasy scales, yellowish crusts. What skin disorder does the nurse expect the patient to be treated for?

The nurse is taking care of a burn patient with deep partial-thickness burns. Which of the following factors can contribute to fluid imbalance in burn patients?

The nurse is reviewing the care plan with the dietician or nutritionist for a burn client. The nurse knows which of the following factors contribute to the increased metabolic demands in burn patients?

A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

A nurse in a provider's office is caring for a client who has tinea pedis. Which of the following findings should the nurse expect?