Chapter 61 Medical Surgical Nursing Preparation For Practice 2nd Edition

Chapter 61  Medical Surgical Nursing Preparation For Practice 2nd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCMA
Which information will the nurse collect to assist in the classification of a burn injury as minor, moderate, or major?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Location of the burns on the body
2. The history of the event and location where the injury occurred
3. Any concurrent injuries
4. The time the injury occurred
5. The causative agent
Correct Answer: 1,2,3,5
Rationale 1: The location of the burns on the body is one of the important determinates of classification. For example, burns of the face and hands are always considered major burns.
Rationale 2: If the injury occurred in an enclosed area, such as a house, there also may be inhalation injuries that require special consideration and treatment. Inhalation injuries are considered major burns.
Rationale 3: If complicated injuries such as those from multiple traumas are present, the burn is considered a major burn.
Rationale 4: The time of the burn is not a burn classification criterion.
Rationale 5: The cause or manner of the burn is included in classification. For example, electrical burns are major burns.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 61-1

Question 2
Type: MCSA
The nurse is admitting a 25-year-old patient to the emergency department with partial-thickness injuries over 20% of the total body surface area, involving both lower legs. According to American Burn Association (ABA) guidelines, the nurse would classify this as which level of burn?
1. Minor
2. Major
3. Moderate
4. Severe
Correct Answer: 3
Rationale 1: A minor burn is a partial-thickness injury that involves less than 15% of total body surface area (TBSA) in adults.
Rationale 2: A major burn is a partial-thickness injury that involves more than 25% of total body surface area in adults (TBSA) or a full-thickness injury over 10% or more of TBSA.
Rationale 3: A moderate injury is a partial-thickness injury that involves between 15% and 25% of total body surface area in adults.
Rationale 4: Severe is not a classification used by the ABA.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 61-1

Question 3
Type: MCSA
The nurse has admitted a patient who sustained a partial-thickness burn injury of 28% of total body surface area (TBSA) and a full-thickness injury of 30% of TBSA. Which American Burn Association (ABA) classification would the nurse assign to this injury?
1. Moderate
2. Major
3. Superficial
4. Minor
Correct Answer: 2
Rationale 1: Partial-thickness injuries between 15% and 25% of total body surface area in adults and full-thickness injuries greater than 10% of TBSA not involving the ears, eyes, face, hands, feet, and perineum are moderate injuries.
Rationale 2: Partial-thickness injuries involving greater than 25% of total body surface area in adults and full-thickness injuries involving 10% or greater of TBSA are considered major burns.
Rationale 3: Superficial is not an ABA burn injury classification.
Rationale 4: Partial-thickness injuries of less than 15% of total body surface area (TBSA) in adults and full-thickness injuries less than 2% of TBSA not involving the ears, eyes, face, hands, feet, and perineum are considered minor injuries.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 61-1

Question 4
Type: MCMA
A patient sustained a radiation injury in an accident at a nuclear power plant. Which assessment questions would the nurse ask to determine the depth of this injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. “How close were you to the source?”
2. “How long were you exposed to the source?”
3. “How hot did the source get?”
4. “Was steam produced during the accident?”
5. “Where did the radiation enter and exit your body?”
Correct Answer: 1,2
Rationale 1: The depth of a radiation injury depends in part on how close the individual was to the source.
Rationale 2: The depth of a radiation injury depends in part on the length of time of exposure.
Rationale 3: The temperature of the source is relevant to the depth and severity of thermal and scald injuries.
Rationale 4: Steam is relevant to the severity of scald injuries.
Rationale 5: Entry and exit wounds occur with electrical injuries.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 61-3