The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)
distributive shock
cardiogenic shock
obstructive shock
hypovolemic shock
neurogenic shock
Correct Answer : A,B
A. Distributive shock
Severe burns lead to systemic inflammatory response syndrome (SIRS), causing massive vasodilation, similar to septic shock (a type of distributive shock).
D. Hypovolemic shock
Fluid loss from burns leads to hypovolemic shock, which is the most common type of shock seen in burn patients.
B. Cardiogenic shock
Cardiogenic shock is caused by heart failure and is not a primary concern in burn injuries.
C. Obstructive shock
Obstructive shock (e.g., tension pneumothorax, cardiac tamponade) does not occur in burn patients unless another condition is present.
E. Neurogenic shock
Neurogenic shock occurs from spinal cord injuries, not burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inability to understand directions
The client's issue is with motor coordination, not comprehension.
B. Lesion of cranial nerve IX
Cranial nerve IX (Glossopharyngeal) is associated with swallowing and taste, not motor coordination.
C. Dysfunction of the cerebellum
The cerebellum controls coordination and fine motor movements. The client's inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.
D. Vestibular disease
Vestibular disorders cause dizziness, vertigo, and balance problems but do not typically affect rapid alternating movements.
Correct Answer is C
Explanation
A. Follows an object with eyes without nystagmus or strabismus
Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control eye movement. CN XI does not control eye movement.
B. Moves the tongue out midline without tremors or deviation
Cranial nerve XII (hypoglossal nerve) controls tongue movement.
C. Moves the head and shoulders against resistance with equal strength
Cranial nerve XI (spinal accessory nerve) controls the sternocleidomastoid and trapezius muscles. If intact, the client can shrug shoulders and turn the head against resistance with equal strength.
D. Demonstrates full range of the neck
Full range of motion in the neck involves multiple muscles, not just those innervated by CN XI.
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