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Questions and Answers
Which of the following is the priority nursing action for a client with a burn injury?
Which of the following is the priority nursing action for a client with a burn injury?
- Initiating nutritional support
- Administering pain medication as needed
- Providing wound care
- Assessing for airway patency (correct)
For which of the following burn depths would skin grafting most likely be necessary?
For which of the following burn depths would skin grafting most likely be necessary?
- Deep partial-thickness burn (correct)
- Superficial-thickness burn
- Superficial partial-thickness burn
- Superficial partial-thickness burn with prolonged healing
A burn that extends deeper into the dermis, has a mottled pink to red base with edema, and large blisters is classified as what?
A burn that extends deeper into the dermis, has a mottled pink to red base with edema, and large blisters is classified as what?
- Deep partial-thickness burn
- Superficial-thickness burn
- Full-thickness burn
- Superficial partial-thickness burn (correct)
Which characteristic distinguishes a superficial-thickness burn from a superficial partial-thickness burn?
Which characteristic distinguishes a superficial-thickness burn from a superficial partial-thickness burn?
What is the primary concern when a large burn affects all the major systems of the body?
What is the primary concern when a large burn affects all the major systems of the body?
What is the expected healing time for a superficial-thickness burn?
What is the expected healing time for a superficial-thickness burn?
Which of the following characteristics is associated with a deep partial-thickness burn?
Which of the following characteristics is associated with a deep partial-thickness burn?
Why is it important to elevate the extremities of a client with burn injuries if no fractures are present?
Why is it important to elevate the extremities of a client with burn injuries if no fractures are present?
A child has burns covering 15% of their total body surface area. How would this burn be classified?
A child has burns covering 15% of their total body surface area. How would this burn be classified?
Which of the following indicates a burn affecting all major systems of the body?
Which of the following indicates a burn affecting all major systems of the body?
What is the rationale for maintaining a client with extensive burns in NPO (nothing by mouth) status initially?
What is the rationale for maintaining a client with extensive burns in NPO (nothing by mouth) status initially?
After a burn injury, what is the primary reason for initiating intravenous (IV) fluid replacement?
After a burn injury, what is the primary reason for initiating intravenous (IV) fluid replacement?
A client presents with a burn that is painful with a tingling sensation, and the pain is eased by cooling. What type of burn is this most likely to be?
A client presents with a burn that is painful with a tingling sensation, and the pain is eased by cooling. What type of burn is this most likely to be?
What is a key characteristic of a superficial partial-thickness burn?
What is a key characteristic of a superficial partial-thickness burn?
Why are children younger than 4 years old and older adults at a higher risk of mortality from burn injuries?
Why are children younger than 4 years old and older adults at a higher risk of mortality from burn injuries?
For which of the following situations would mortality rate be higher in burn victims?
For which of the following situations would mortality rate be higher in burn victims?
A client's burn wound has a wet, shiny, and weeping surface. Which type of burn is most likely present?
A client's burn wound has a wet, shiny, and weeping surface. Which type of burn is most likely present?
In the initial management of a burn injury, what is the purpose of administering oxygen?
In the initial management of a burn injury, what is the purpose of administering oxygen?
What is the expected outcome for a superficial-thickness burn regarding scarring?
What is the expected outcome for a superficial-thickness burn regarding scarring?
Why might grafts be used in the healing process of superficial partial thickness burns?
Why might grafts be used in the healing process of superficial partial thickness burns?
Which of the following processes defines a burn injury?
Which of the following processes defines a burn injury?
Why is obtaining vital signs a priority nursing action in the care of a client with burn injury?
Why is obtaining vital signs a priority nursing action in the care of a client with burn injury?
What does mottled skin indicate on a patient with a burn wound?
What does mottled skin indicate on a patient with a burn wound?
Why is pain not eased by cooling on deep partial thickness burns?
Why is pain not eased by cooling on deep partial thickness burns?
An adult client has burns covering 30% of their total body surface area. How would this burn be classified?
An adult client has burns covering 30% of their total body surface area. How would this burn be classified?
What is the main difference between small burns and large or extensive burns?
What is the main difference between small burns and large or extensive burns?
What should the nurse do if a patient with burns has obvious fractures?
What should the nurse do if a patient with burns has obvious fractures?
What does blanching mean when assessing a patient with burn wounds?
What does blanching mean when assessing a patient with burn wounds?
What is the commonality between superficial partial thickness burns and deep partial thickness burns?
What is the commonality between superficial partial thickness burns and deep partial thickness burns?
What is the primary reason for assisting to initiate an intravenous (IV) line and begin fluid replacement as prescribed to a client?
What is the primary reason for assisting to initiate an intravenous (IV) line and begin fluid replacement as prescribed to a client?
Which of the following is a sign of a superficial partial thickness burn?
Which of the following is a sign of a superficial partial thickness burn?
What is the primary reason for assessing airway patency in a patient with burn injury?
What is the primary reason for assessing airway patency in a patient with burn injury?
What is the main sign of the skin with superficial burn?
What is the main sign of the skin with superficial burn?
Which vital sign is the most important to obtain with a burn patient?
Which vital sign is the most important to obtain with a burn patient?
A construction worker gets burned by hot metal, damaging the body by cell destruction. What kind of agent causes this burn injury?
A construction worker gets burned by hot metal, damaging the body by cell destruction. What kind of agent causes this burn injury?
What is an indication that a deep partial thickness burn is turning into full thickness burn?
What is an indication that a deep partial thickness burn is turning into full thickness burn?
Which of the following burn types does not occur with blister formation?
Which of the following burn types does not occur with blister formation?
How long does it take for a deep partial thickness burn to generally heal?
How long does it take for a deep partial thickness burn to generally heal?
Flashcards
Burn Injury
Burn Injury
Cell destruction of the skin layers caused by heat, friction, electricity, radiation, or chemicals.
Small Burns
Small Burns
The response of the body to injury is localized to the injured area.
Large or Extensive Burns
Large or Extensive Burns
Major burns consist of 25%+ total body surface area for an adult or 10%+ for a child.
Priority Nursing Actions for Burns
Priority Nursing Actions for Burns
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Superficial-Thickness Burn
Superficial-Thickness Burn
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Superficial Partial-Thickness Burn
Superficial Partial-Thickness Burn
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Deep Partial-Thickness Burn
Deep Partial-Thickness Burn
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Study Notes
- Burn injury involves cell destruction of skin layers caused by heat, friction, electricity, radiation, or chemicals.
Types of Burns
- Small burns involve a localized response to the injured area in the body.
- Large or extensive burns consist of 25% or more of total body surface area for adults.
- Large or extensive burns consist of 10% or more of the total body surface area for children.
- The body's response to large or extensive burns is systemic.
- Large or extensive burns affect all major systems of the body.
Priority Nursing Actions
- Assess for airway patency.
- Administer oxygen as prescribed.
- Obtain vital signs.
- Assist to initiate an IV line and begin fluid replacement as prescribed.
- Elevate the extremities if no fractures are obvious.
- Keep the client warm and maintain an NPO (nothing by mouth) status.
Superficial-Thickness Burn
- Involves injury to the epidermis.
- The blood supply to the dermis is still intact.
- Mild to severe erythema (pink to red) is present.
- There are no blisters.
- The skin blanches with pressure.
- Burns are painful, with a tingling sensation.
- Pain is eased by cooling.
- Discomfort lasts about 48 hours.
- Healing occurs in approximately 3 to 6 days.
- No scarring occurs
- Skin grafts are not required.
Superficial Partial-Thickness Burn
- Involves injury deeper into the dermis.
- Blood supply is reduced.
- Large blisters may cover an extensive area.
- Edema is present.
- Mottled pink to red base and a broken epidermis, with a wet, shiny, and weeping surface are characteristic.
- Burns are painful and sensitive to cold air.
- It heals in 10 to 21 days with no scarring, but some minor pigment changes may occur.
- Grafts may be used if the healing process is prolonged.
Deep Partial-Thickness Burn
- Extends deeper into the skin dermis.
- Blister formation usually does not occur because the dead tissue layer is thick and sticks to underlying viable dermis.
- Wound surface is red and dry with white areas in deeper parts.
- Can convert to a full-thickness burn when tissue damage increases with infection, hypoxia, or ischemia.
- Generally, it heals in 3 to 6 weeks.
- Scar formation results.
- Skin grafting may be necessary.
Mortality Rate Considerations:
- Mortality rate is higher for children younger than 4 years old, particularly for children from birth to 1 year of age, and for clients older than 65 years.
- Mortality rate is higher when the client has a pre-existing disorder at the time of the burn injury.
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