While developing a care plan for a client with full thickness burns, the nurse determines an appropriate goal is to maintain alignment of joints. The goal is to prevent which of the following complications associated with full thickness burns?

Contracture

Wound breakdown

Heterotopic ossification

Neuropathy

Answer and Explanation

The Correct Answer is A

Choice A reason: Full-thickness burns destroy all skin layers, leading to scar tissue formation. Without joint alignment and mobility, scar tissue can tighten, causing contractures that limit movement. Maintaining joint alignment through positioning and therapy prevents these deformities, preserving function and reducing the risk of permanent joint immobility in burn recovery.

Choice B reason: Wound breakdown occurs due to infection or poor healing in burns but is not directly related to joint alignment. Maintaining alignment prevents contractures, not wound integrity issues. Wound breakdown is managed with infection control and dressings, making this complication unrelated to the goal of joint positioning.

Choice C reason: Heterotopic ossification involves abnormal bone growth in soft tissues, sometimes seen in severe burns, but it is not prevented by joint alignment. It results from prolonged immobility or trauma, not directly from burn scarring. Joint alignment targets contractures, making this an incorrect complication for the stated goal.

Choice D reason: Neuropathy in burns may result from nerve damage or compression but is not primarily prevented by joint alignment. Maintaining alignment focuses on preventing scar tissue contractures, not neurological complications. Neuropathy management involves pain control and monitoring, not positioning, making this unrelated to the care plan’s goal.

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Correct Answer is C

Explanation

Choice A reason: Low blood glucose (hypoglycemia) can cause cool, moist skin and tachycardia due to sympathetic activation, but falling blood pressure is less typical unless severe. Femur fractures are associated with significant blood loss, and the symptoms align more closely with hypovolemic shock from hemorrhage than metabolic disturbances like hypoglycemia.

Choice B reason: High blood glucose (hyperglycemia) may cause tachycardia and diaphoresis in severe cases (e.g., diabetic ketoacidosis), but cool, moist skin and falling blood pressure are not primary features. These symptoms are more indicative of hypovolemia from blood loss, as femur fractures can cause significant internal bleeding, making hyperglycemia unlikely.

Choice C reason: Hemorrhage from a femur fracture causes hypovolemic shock, characterized by cool, moist skin (due to vasoconstriction), increased heart rate (compensatory tachycardia), and falling blood pressure (due to volume loss). This is a life-threatening condition requiring urgent fluid resuscitation and hemorrhage control, aligning with the symptoms described and the injury’s severity.

Choice D reason: Fluid volume excess typically presents with edema, hypertension, and bounding pulses, not cool, moist skin or falling blood pressure. A femur fracture is unlikely to cause fluid overload acutely. The symptoms suggest hypovolemia from blood loss, not excess fluid, making this an incorrect diagnosis for the client’s presentation.

A. Respiratory rate of 28/min and temperature of 101°F B. Complaining of difficulty swallowing and nausea C. Complaining of chest pain and diaphoretic D. Blood pressure 100/60 mm Hg, right wrist painful and swollen

Correct Answer is C

Explanation

Choice A reason: A respiratory rate of 28/min and temperature of 101°F suggest tachypnea and fever, possibly due to infection or inflammation. While concerning, these do not indicate immediate life-threatening issues like acute coronary syndrome. The ABCDE approach prioritizes circulation (chest pain) over respiratory rate, making this a lower priority.

Choice B reason: Difficulty swallowing and nausea may indicate an esophageal issue or infection but are not immediately life-threatening. These symptoms do not compromise airway, breathing, or circulation acutely in the ABCDE framework. Chest pain with diaphoresis suggests a cardiac emergency, which takes precedence due to potential for rapid deterioration.

Choice C reason: Chest pain with diaphoresis is highly suggestive of acute coronary syndrome, such as myocardial infarction, a life-threatening emergency. The ABCDE approach prioritizes circulation, and these symptoms indicate potential cardiac ischemia, requiring immediate assessment, ECG, and intervention to prevent cardiac arrest, making this the highest priority client.

Choice D reason: Blood pressure of 100/60 mm Hg with a painful, swollen wrist suggests a musculoskeletal injury with mild hypotension. While concerning, it is not immediately life-threatening compared to chest pain with diaphoresis, which may indicate acute coronary syndrome. The ABCDE approach prioritizes circulation issues like cardiac events over stable injuries.

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While developing a care plan for a client with full thickness burns, the nurse determines an appropriate goal is to maintain alignment of joints. The goal is to prevent which of the following complications associated with full thickness burns?

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A client who has broken his femur presents to the emergency department with the following signs and symptoms: cool, moist skin, increased heart rate, and falling blood pressure. The nurse suspects the client is experiencing:

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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