Febrile Seizure
A child is diagnosed with a febrile seizure. What should the nurse do during a febrile seizure?
A. Restrain the child to prevent injury
B. Place the child in a supine position
C. Administer antipyretics immediately
D. Ensure a safe environment and monitor the child
D. Ensure a safe environment and monitor the child
Frostnip is...
is a type of superficial cold injury that may produce pain, numbness, & pallor of the affected area but is easily relieved by applying warmth
It does not cause tissue damage.
A patient, experiencing a burn that is pale and waxy with large flat blisters, asks the nurse about the severity of the burn and how long it will take to heal. With which of the following should the nurse respond to this patient?
1. The wound is a deep partial-thickness burn, and will take more than three weeks to heal.
2. The wound is a partial-thickness burn, and could take up to two weeks to heal.
3. The wound is a superficial burn, and will take up to three weeks to heal.
4. The wound is a full-thickness burn and will take one to two weeks to heal.
5. Wound healing is individualized.
Correct Answer: 1
Rationale: The wound described is a deep partial-thickness burn. Deep partial-thickness wounds will take more than three weeks to heal.
A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this burn as which of the following?
Select all that apply.
1. a superficial partial-thickness burn
2. a thermal burn
3. a superficial burn
4. a deep partial-thickness burn
5. a full-thickness burn
Correct Answer: 1,2
Rationale: Superficial partial-thickness burn if often bright red, has a moist, glistening appearance and blister formation.
In order for the nurse to correctly classify a burn injury, which of the following does the nurse need to assess?
Select all that apply.
1. the depth of the burn
2. extent of burns on the body
3. the causative agent and the duration of exposure.
4. location of burns on the body
5. the time that the burn occurred
Correct Answer: 1,2,3,4
Types of febrile seizures? what are the differences?
simple and complex
simple are generalized and last less than 15 minutes and do not recur in 24 hours. A complex lasts more than 15 minutes or occurs another time within 24 hours and includes postictal weakness.
Which client is at the greatest risk for hypothermia?
A.
An 89-year-old client on a fixed income during cold winter months
B.
A 3-hour-old infant swaddled in a blanket, wearing a hat, and being held by the mother
C.
A worker who repairs industrial freezers
D.
A pregnant woman in her first trimester
A
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250 mL/hour
ANS: C
Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?
a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the fingers.
c. Assist the patient to a supine position with a small pillow under the head.
d. Position the patient in a side-lying position with rolled towel under the neck.
ANS: B
The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures.
A nurse is teaching a class of older adults at a senior center about household cleaning agents that may cause burns. Which agents should be included in these instructions?
(Select all that apply)
1. drain cleaners
2. household ammonia
3. oven cleaner
4. toiler bowl cleaner
5. lemon oil furniture polish
Correct Answer: 1,2,3,4
Rationale: All of the products except for the furniture polish can cause burns since they are either alkalis or acids.
What factors are associated with an increased risk of febrile seizures?
The nurse caring for a client with hypothermia understands the compensatory mechanisms that are activated during this condition to decrease oxygen demands on the body. Which clinical manifestation should the nurse expect upon assessment for this client? (Select all that apply.)
A.
Increased heart rate
B.
Decreased heart rate
C.
Increased GI motility
D.
Increased respiratory rate
E.
Decreased respiratory rate
BE
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds.
ANS: B
The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur
While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination?
a. Use sterile gloves when removing old dressings.
b. Wear gowns, caps, masks, and gloves during all care of the patient.
c. Administer IV antibiotics to prevent bacterial colonization of wounds.
d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.
ANS: B
Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.
A nurse sees a patient get struck by lightning during a thunder storm on a golf course. What should be the FIRST action by the nurse?
1. Check breathing and circulation.
2. Look for entrance and exit wounds.
3. Cover the patient to prevent heat loss.
4. Move the patient indoors to a dry place.
5. Get the patient up off the ground.
Correct Answer: 1
Rationale: Cardiopulmonary arrest is the most common cause of death from lightening. Respiratory and cardiac status should be assessed immediately to determine if CPR is necessary. All other actions are secondary.
Which characteristic is true for complex febrile seizures?
he nurse is caring for a client diagnosed with frostbite. The nurse understands that which process occurs when tissue freezes? (Select all that apply.)
A.
Ice crystals form.
B.
Tissues and cells become edematous.
C.
Vascular permeability occurs.
D.
Thinning of the blood occurs.
E.
Intracellular potassium increases.
ABC
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction
ANS: B
With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output.
ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.
A patient arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask in determining the possible severity of the burn injury? Select all that apply.
1. What type of current was involved?
2. How long was the patient in contact with the current?
3. How much voltage was involved?
4. Where was the patient when the burn occurred?
5. What was the point of contact with the current?
Correct Answer: 1,2,3
Rationale: The severity of electrical burns depends on the type and duration of the current and amount of voltage. Location is not important in determining possible severity. Location is not important in determining possible severity.
Prevention of future febrile seizures:
Anti-seizure medication
• Acetaminophen or ibuprofen
• For the children who are prone to febrile seizure
A patient presents with frostbite on the fingers. The skin appears white and feels numb to touch. What degree of frostbite should the nurse suspect?
A) First degree
B) Second degree
C) Third degree
D) Fourth degree
C) Third degree
Rationale: Third-degree frostbite typically involves white or mottled skin, numbness, and a lack of sensitivity. First-degree frostbite usually presents with redness and swelling, while fourth-degree involves deeper tissue damage.
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
ANS: C
The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5000 kcal per day.
d. Administer multiple vitamins and minerals in the IV solution.
ANS: A
Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.
A patient comes into the emergency department with a chemical burn from contact with lye. Assessment and treatment of this patient will be based on what knowledge regarding this type of burn? (Select all that apply)
1. This is an alkali burn.
2. This type of burn tends to be deeper.
3. This is an acid burn.
4. This type of burn will be easier to neutralize.
5. This type of burn tends to be more superficial.
Correct Answer: 1,2
Rationale: This is an alkali burn which is more difficult to neutralize than an acid burn and tends to have a deeper penetration and be more severe than a burn caused by an acid.