N472 Final Exam | Complete Solutions (Verified)

N472 Final Exam | Complete Solutions (Verified) Most burns occur: A. At the workplace B. At home C. In vehicles D. In emergency situations Who is at highest risk for burns? (Select All that Apply) A. Infants B. Young children C. Teens D. Adults E. Older Adults What are nursing goals related to burns? (Select All that Apply) A. Prevention of burns B. Instituting life saving measures for severely burned C. Early specialized care to prevent disability/disfigurement D. Maintenance of burned individual's self esteem E. Rehabilitation through reconstructive surgeries/rehab What are the classifications of burns? (Select All that Apply) A. Arson-induced B. Superficial partial thickness C. Appliance-induced D. Deep partial thickness E. Full thickness What are the zones of burn injury? (Select All that Apply) A. Zone of Coagulation B. Zone of Hyperemia C. Zone of Thickness D. Zone of Stasis E. Zone of Infection What are factors to consider in determining burn depth? (Select All that Apply) A. How the injury occurred B. Causative agent C. Temperature of agent D. Duration of contact with the agent E. Thickness of the skin What are the classifications of burns based on extent of injury? (Select All that Apply) A. Moderate, complicated burn B. Moderate, uncomplicated burn C. Major Burn D. Minor Burn E. Serious Burn T/F: First Degree Burns cause blisters that form after burn injury -up to 3 days. F: Second Degree (Partial Thickness) Burns T/F: Second degree burns will heal on their own with clean environment at normal body temperature True What is important to insure in cases of second degree burns? (Select All that Apply) A. Thermoregulation B. Fluid regulation C. Risk of infection D. Risk of deterioration E. Sensation T/F: In Third Degree Burns (Full Thickness), the entire dermal layer is destroyed. True T/F: In Third Degree Burns (Full Thickness), skin function is not lost. False: skin function IS lost T/F: In Third Degree Burns (Full Thickness), grafting is required. True T/F: Determination of burn size is crucial for estimating initial fluid resuscitation. True Which of the following are methods for determining burn size? (Select All that Apply) A. Rules of Nines B. Lund-Browder Method C. Russell Method D. Palmar Method E. Rule of Stasis T/F: The Rules of Nines does not work well for children. True T/F: According to the Palmar Method, the patient's palm plus fingers is about 0.5% of their body. False: 1% T/F: The Palmar Method is the most accurate method for determining burn size. False: Lund-Browder Method T/F: The Lund-Browder Method accounts for age, location, depth when determining burn size and initial fluid resuscitation needed. True T/F: The Rules of Nines asserts that, on adults, the head and arms each account for 9% of the body; the anterior torso, posterior torso, and legs each account for 18% of the body; and the genital area accounts for 1% of the body. True T/F: Burns are caused by a transfer of energy from a heat source to the body. True What are causes of burns? (Select All that Apply) A. Solar B. Artificial C. Chemical D. Radiation E. Thermal (including electrical) T/F: Burns less than 30% TBSA produce primarily a local response. False: 25% T/F: Burns more than 25% may produce a local and systemic response and are considered major burns. True A systemic response to burns includes: A. Release of adrenaline into the bloodstream B. Release of cytokines and other mediators into systemic circulation C. Headache, nausea, and vomiting D. Change in level of consciousness Fluid shifts and shock result in: A. Tissue hyperperfusion and organ hypofunction B. Tissue hyperperfusion and organ hyperfunction C. Tissue hypoperfusion and organ hypofunction D. Tissue hypoperfusion and organ hyperfunction What pulmonary injuries can result from major burns? (Select All that Apply) A. Upper airway B. Inhalation below the glottis C. Pulmonary embolism D. Carbon monoxide poisoning E. Restrictive defects What are the phases of burn injury? (Select All that Apply) A. Emergent/Resuscitative phase B. Healing/Recovery phase C. Acute/Intermediate phase D. Rehabilitation phase E. Onset phase T/F: Emergent/Resuscitative phase of burn injury lasts from onset of injury to completion of fluid resuscitation. True T/F: Acute or intermediate phase of burn injury lasts from beginning of diuresis to wound closure. True T/F: Rehabilitation phase of burn injury lasts from wound closure to return to optimal physical and psychosocial adjustment. True T/F: In on-the-scene care, the rescuer should ice the burn. False: never ice the burn, cool the burn T/F: In on-the-scene care, chemical burns should be flushed with lukewarm water for 15-20 minutes. True T/F: Saline and cool water soaks can be used to treat burns. False: hypothermia is a risk T/F: In on-the-scene care, oxygen and small-bore IVs should be initiated. False: large-bore IVs T/F: Treat patient with falls and electrical injuries as for potential cervical spine injury. True T/F: Patient with burns exceeding 20% to 25% should have an NG tube inserted and placed to suction. True T/F: Patients with electrical burns should have ECG. True T/F: A Foley catheter is not necessary during the emergent burn phase. False: foley should be inserted T/F: IV or PO pain medication can be given to burn victims upon arrival to hospital in emergent phase. False: IV meds only T/F: 100% humidified O2 should be given to burns victims in emergent phase. True T/F: An escharatomy is the cutting down to SQ fat to cut out burned skin. True T/F: In caring for inhalation injuries or burns to the head/face, ETT should be measured from the lip. False: measure from the teeth T/F: Acute/Intermediate phase of burn injury lasts 36 to 72 hours after injury. False: 48 to 72 hours T/F: Rehabilitation is begun as early as possible in the emergent phase and extends for a long period after the injury. True T/F: In emergent phase, trauma causes release of potassium into extracellular fluid (hyperkalemia) True T/F: In emergent phase, sodium traps in edema fluid and shifts into cells as potassium is released (hyponatremia) True T/F: In acute phase, sodium is lost with diuresis and due to dilution as fluid enter vascular space (hyponatremia) True T/F: In acute phase, potassium shifts from extracellular fluid into cells (potential hypokalemia) True Formulas are only a guide for burn care fluid resuscitation. How often must the patient' s response to fluid therapy (heart rate, blood pressure, and urine output) be evaluated? A. Every hour B. Every 2 hours C. Every 3 hours D. Every 4 hours What are types of wound debridement? (Select All that Apply) A. Mechanical B. Hydraulically C. Surgical D. Natural E. Electrical What are types of burn pain? (Select All that Apply) A. Emergent B. Procedural C. Breakthrough D. Constant E. Background/Resting T/F: Morphine and fentanyl are used IV to treat burn pain. True T/F: Nutritional support for burn victims is based on patient preburn status and % of TBSA burned. True T/F: Independent feeding is preferred for nutritional support of burn victims. False: Enteral route T/F: Nasogastric feedings are frequently used to maintain nutritional status with a lower risk of aspiration in a patient with poor appetite, weakness, or other problems. False: Jejunal T/F: Shock is the condition in which tissue perfusion is inadequate to deliver oxygen, nutrients to support vital organs, cellular function. True T/F: Shock only affects some body systems. False: all body systems Which are classifications of shock? (Select All that Apply) A. Hypovolemic B. Cardiogenic C. Neurogenic D. Anaphylactic E. Septic T/F: Cardiogenic shock is a shock state resulting from impairment or failure of myocardium and decreased cardiac output. True T/F: Neurogenic shock is a shock state resulting from loss of sympathetic tone causing relative hypovolemia. True T/F: Anaphylactic shock is a circulatory shock state resulting from severe allergic reaction producing overwhelming systemic vasodilation, relative hypovolemia. True T/F: Septic shock is a shock state resulting from overwhelming infection causing relative hypovolemia. True T/F: When the ICF becomes acidic, cells shrink and become permeable to electrolytes. False: swell T/F: When the Na-K pump is impaired in shock, mitochondrial damage occurs, cells die early, and organ damage ensues. True T/F: Mean Arterial BP (MAP) = Cardiac Output X Peripheral Vascular Resistance. True T/F: Cardiac output is calculated by adding stroke volume and heart rate. True T/F: Peripheral Vascular Resistance is the diameter of the veins. False: arterioles T/F: MAP must be 65 mm Hg for cellular aerobic metabolism. True What are the stages of shock? (Select All that Apply) A. Stagnant B. Progressive C. Irreversible D. Compensatory E. Emergent T/F: Aggressive therapy should be initiated within 12 hours for shock, especially septic shock. Fasle: 6 hours T/F: In compensatory stage of shock, SNS causes vasoconstriction, increased HR, increased heart contractility, maintaining BP and cardiac output. True T/F: Systolic BP - Diastolic BP = Pulse pressure. True T/F: Normal pulse pressure is 20-50mmHg. False: 30-40mmHg T/F: In compensatory stage of shock, respiratory rate decreases due to acidosis, may cause compensatory respiratory alkalosis False: increases In compensatory stage of shock, body shunts blood from skin, kidneys, GI tract, resulting in: (Select All that Apply) A. cool, clammy skin B. hypoactive bowel sounds C. increased basal temperature D. decreased urine output E. decreased respiratory rate T/F: In progressive stage of shock, mechanisms that regulate BP can no longer compensate, and the BP and MAP decrease. True T/F: MAP = SBP + 2(DBP)/ 3 True T/F: As MAP falls below 70, GFR can still be maintained. False: cannot T/F: In progressive stage of shock, capillary permeability decreases causing peripheral edema and decreased venous return to the heart False: increases T/F: Disseminated intravascular coagulation (DIC) may occur as cause or complication of shock. True T/F: In the irreversible stage of shock, organ damage is so severe that patient does not respond to treatment and cannot survive. True T/F: Crystalloid and colloid solutions are not effective fluid replacements in general treatment of shock. False: are effective T/F: Crystalloids are electrolyte solutions and colloids are large molecule IV solutions (ex. albumin). True T/F: Glycemic control between 120-140 is crucial for nutritional support during shock. False: 140-180 T/F: Enteral or parenteral nutrition should be initiated as soon as possible during shock. True T/F: Normal CVP is 3-12mmHg. True T/F: CVP monitoring consists of subclavian or jugular vein access and the tip sits in right atrium and measures right atrial pressure in response to fluid replacement. True These techniques are crucial parts of a CLABSI Bundle: (Select All that Apply) A. Change administrations sets for continuous infusions no more frequently than every 4 days, but at least every 7 days. B. Follow proper insertion practices C. Promptly remove unnecessary central lines D. Wash site with sterile water E. Handle and maintain central lines appropriately These are types of Distributive Shock: (Select All that Apply) A. Hypovolemic B. Cardiogenic C. Neurogenic D. Anaphylactic E. Septic T/F: Symptoms of neurogenic shock are differentiated from other forms of shock, by the lack of signs of the compensatory mechanisms triggered by the sympathetic nervous system on other forms of shock via the release. True T/F: In neurogenic shock, the body loses its ability to activate the sympathetic nervous system so that only parasympathetic tone remains. True T/F: Neurogenic shock is found in about half of people who suffer spinal cord injury within the first 24 hours, and usually doesn't go away for one to three weeks. True What are risk factors for neurogenic shock? (Select All that Apply) A. Brain stem injury B. Severe scoliosis C. Spinal anesthesia D. spinal cord injury above the level of T6 or higher E. spinal cord injury below the level of T6 or lower What are symptoms of neurogenic shock? (Select All that Apply) A. hypotension and decreased cardiac output B. Bradycardia and venous pooling C. Warm, flushed skin from vasodilation or priapism D. Hypovolemia E. Hypothermia T/F: Patients in neurogenic shock heavily perspire. False: cannot perspire What are necessary nursing interventions for patients with neurogenic shock? (Select All that Apply) A. Protecting the airway if injury is C4 B. Keeping the bed flat and patient in collar C. replace vascular volume with IV fluids D. DVT prophylaxis of pneumatic compression E. Heparin administration T/F: In neurogenic shock, dopamine is given to decrease vasoconstriction and heart rate. False: increase T/F: In neurogenic shock, vasopressin is given as an antidiuretic. True T/F: In neurogenic shock, ephedrine and norepinephrine are given as vasopressors. True T/F: In neurogenic shock, atropine is given to treat tachycardia. False: bradycardia T/F: Spinal shock refers to flaccid paralysis and loss of spinal reflexes following a spinal cord injury. True T/F: Hypovolemic shock is the most common form of shock. True T/F: Hypovolemic shock is characterized by increased intravascular volume due to fluid overload. False: decreased; loss T/F: ICF is 1/3 of total body fluid. False: 2/3 T/F: ECF = intravascular fluid + interstitial fluid. True Hypovolemic shock is: A. 5% - 10% loss of intravascular volume B. 10% - 15% loss of intravascular volume C. 15% - 30% loss of intravascular volume D. 30% - 40% loss of intravascular volume T/F: The pathophysiology of hypovolemic shock is decreased blood volume decreased venous return decreased stroke volume decreased cardiac output decreased tissue perfusion decreased oxygenation. True