Chapter 35 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 35 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

Victims of a house fire are being admitted through the emergency department. Of the patients, the nurse realizes that which will have the greatest general risk for mortality from the burn injuries?

1. 25-year-old pregnant female
2. 49-year-old male who smokes
3. 75-year-old female with arthritis
4. 50-year-old male with coronary artery disease

Correct Answer: 3

Rationale 1: Pregnancy is not a factor in increasing mortality from burn injury.

Rationale 2: This patient does not have the greatest risk of mortality from this burn injury.

Rationale 3: People of advancing age have thinner skin, with decreased microcirculation and an increased susceptibility to infection. All of these factors not only put them at a greater risk for burn injuries, but also lead to a greater morbidity and mortality.

Rationale 4: Coronary artery disease does not make this patient at higher risk than another patient also injured in this fire.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-1

 

Question 2

Type: MCSA

The nurse is caring for a patient admitted with thermal burns. The nurse will plan to monitor the patient closely over the next 2 to 3 days for development of which most serious complication?

1. Pain
2. Burn shock
3. Continuation of the burn process below the level of obvious injury
4. Hypervolemia

Correct Answer: 2

Rationale 1: Thermal burns are painful, but this is not the most serious complication listed.

Rationale 2: Thermal burns produce microvascular and inflammatory responses within minutes of the injury; however, the effects from these two responses can last from 2 to 3 days. Substances released by damaged cells increase vascular permeability, causing fluid, electrolytes, and proteins to leak into the interstitial space. The fluid shift from intravascular to interstitial spaces may cause a hypovolemic shock state, which is frequently referred to as burn shock.

Rationale 3: Continuation of the burn process below the level of obvious injury is a characteristic of an alkaline burn not a thermal burn.

Rationale 4: It would be more likely that the patient would develop hypovolemia.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 35-1

 

Question 3

Type: MCSA

A civilian patient admitted with frostbite burns to his feet is receiving pain medication, fluid replacement, and is being monitored for any signs of organ dysfunction. What rationale would the nurse provide for this conservative management?

1. Frostbite injuries are not as serious as thermal or chemical burns.
2. The extent of the injury is not obvious.
3. Little is known about other methods to treat frostbite.
4. Aggressive frostbite management is only done in specialty military hospitals.

Correct Answer: 2

Rationale 1: Frostbite injuries can be devastating.

Rationale 2: Since it may take weeks before there is a clear demarcation between viable and nonviable tissue with frostbite injuries, patients are treated conservatively, which includes fluid support, pain management, and ongoing assessment of organ functioning.

Rationale 3: This treatment approach is not related to lack of knowledge of other potential treatments.

Rationale 4: Hospitals of all descriptions generally approach frostbite care conservatively.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 35-1