When providing information to a client in the rehabilitative phase of a burn injury, which of the following will the nurse identify as the goal?
Resume a functional role in society
Pain management
Provide continued full support to the client
Prevent infection
The Correct Answer is A
Choice A reason: This is correct because resuming a functional role in society is the ultimate goal for a client in the rehabilitative phase of a burn injury. The rehabilitative phase begins when wound healing is complete and lasts until physical and psychosocial recovery is achieved. The nurse should help the client regain independence, self-esteem, and quality of life by providing education, counseling, referrals, and resources.
Choice B reason: This is incorrect because pain management is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Pain management is important throughout all phases of burn care, but especially during wound healing and scar formation, which can cause itching, tightness, or hypersensitivity. The nurse should assess the client's pain level and administer analgesics, antipruritics, or moisturizers as ordered.
Choice C reason: This is incorrect because providing continued full support to the client is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Providing continued full support to the client can help them cope with physical and emotional challenges, such as scarring, disfigurement, disability, or depression. The nurse should provide emotional support, active listening, positive feedback, and encouragement to the client.
Choice D reason: This is incorrect because preventing infection is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Preventing infection is crucial during wound healing and grafting, which can be compromised by bacterial colonization or contamination. The nurse should monitor the client's vital signs, wound appearance, and laboratory results, and administer antibiotics or antiseptics as ordered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: This is correct because avoiding swimming underwater can help prevent the worsening of Meniere's disease. Meniere's disease is a disorder of the inner ear that causes episodes of vertigo, tinnitus, hearing loss, and fullness in the ear. Swimming underwater can increase pressure in the ear and trigger an attack. The nurse should advise the client to avoid activities that involve changes in altitude or pressure, such as flying, diving, or climbing.
Choice B reason: This is incorrect because wearing earphones when in crowded places can worsen Meniere's disease. Earphones can increase noise exposure and damage hearing, which is already impaired by Meniere's disease. The nurse should advise the client to avoid loud noises and use hearing aids if needed.
Choice C reason: This is incorrect because keeping eyes open during an acute attack can increase vertigo and nausea. Vertigo is a sensation of spinning or moving when still, which can be caused by Meniere's disease. Keeping eyes open can make vertigo worse by creating a visual mismatch with vestibular signals from the inner ear. The nurse should advise the client to close their eyes or focus on a stationary object during an attack.
Choice D reason: This is correct because sitting or lying down if whirling occurs can help prevent falls or injuries due to vertigo. Whirling is another term for vertigo, which can affect balance and coordination. Sitting or lying down can reduce movement and stabilize posture during an attack. The nurse should advise
the client to avoid driving or operating machinery when experiencing vertigo.
Choice E reason: This is correct because we do not know the exact cause of Meniere's disease. Meniere's disease is thought to be related to abnormal fluid balance or pressure in the inner ear, but what triggers this condition is unknown. The nurse should educate the client about possible risk factors, such as genetics, infections, allergies, autoimmune disorders, or head trauma, but also acknowledge the uncertainty and variability of the disease.
Choice F reason: This is incorrect because damage to the ear from excess noise is not the cause of Meniere's disease. Damage to the ear from excess noise can cause noise-induced hearing loss, which is a type of sensorineural hearing loss that affects the cochlea or the auditory nerve. Meniere's disease is a type of mixed hearing loss that affects both the cochlea and the middle ear. The nurse should not confuse or misinform the client about the cause of their condition.
Correct Answer is D
Explanation
Choice A Reason: The burned area is yellow in color with severe edema is not a finding of a deep partial-thickness burn, but a superficial partial-thickness burn. A superficial partial-thickness burn involves the epidermis and the upper layer of the dermis, causing pain, redness, swelling, and blistering.
Choice B Reason: The burned area is black in color and pain is absent is not a finding of a deep partial-thickness burn, but a full-thickness burn. A full-thickness burn involves the epidermis, dermis, and underlying tissues, causing necrosis, charred skin, and loss of sensation.
Choice C Reason:This description aligns with a superficial partial-thickness (first-degree or mild second-degree) burn rather than a deep partial-thickness burn. Superficial partial-thickness burns involve the epidermis and the upper portion of the dermis. These burns appear pink or red, often accompanied by moisture and blister formation due to fluid leakage from damaged capillaries. They are painful because nerve endings remain intact. Healing occurs within 10 to 21 days without significant scarring.
Choice D Reason:Deep partial-thickness burns extend deeper into the dermis, damaging a larger portion of skin structures, including sweat glands and hair follicles. These burns typically appear red or white and may have a soft eschar (dead tissue), which differentiates them from more superficial burns that do not develop eschar. Unlike full-thickness burns, nerve endings remain partially intact, so the patient may still experience some pain. These burns take more than 21 days to heal and often require skin grafting to prevent complications such as contractures or hypertrophic scarring.
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