Integumentary Disorders Q 50 - Gyan Darpan : Learning Portal
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Saturday, 2 April 2022

Integumentary Disorders Q 50

During the acute phase of a burn, the nurse in-charge should assess which of the following?
    A. Client’s lifestyle
    B. Alcohol use
    C. Tobacco use
    D. Circulatory status

Correct Answer: D. Circulatory status

During the acute phase of a burn, the nurse should assess the client’s circulatory and respiratory status, vital signs, fluid intake, and output, ability to move, bowel sounds, wounds, and mental status. Information about the client’s lifestyle and alcohol and tobacco use may be obtained later when the client’s condition has stabilized.

Option A: Assess color, sensation, movement, peripheral pulses, and capillary refill on extremities with circumferential burns. Compare with findings of unaffected limb. Edema formation can readily compress blood vessels, thereby impeding circulation and increasing venous stasis or edema. Comparisons with unaffected limbs aid in differentiating localized versus systemic problems.
Option B: Obtain BP in unburned extremity when possible. Remove BP cuff after each reading, as indicated. If BP readings must be obtained on an injured extremity, leaving the cuff in place may increase edema formation and reduce perfusion, and convert partial thickness burn to a more serious injury.
Option C: Check for irregular pulses. Cardiac dysrhythmias can occur as a result of electrolyte shifts, electrical injury, or release of myocardial depressant factor, compromising cardiac output.

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