Question

Which assessments would provide the nurse with the MOST accurate information regarding a client in the emergent phase of burn care? ( Select all that apply.)

1.     Extreme thirst

2.     Decreased pulse

3.     Warm and flushed feeling

4.     Decreased bowel sounds

5.     Dehydration

6.     Decreased blood pressure

Answer 1

2. Decreased pulse

The initial response to severe burn injury or early shock state is characterized by a decrease in cardiac output and metabolic rate. The reduction in cardiac output is partially due to hypovolemia

5. Dehydration

Individuals who suffer burns will experience dehydration as a side effect. If the dehydration is severe enough, it can lead to shock. While some doctors may prescribe intravenous fluids following a burn, patients can also help their body become more hydrated through a variety of ways : Drink more water.

6. Decreased blood pressure

The routine clinical signs of hypovolemia in adult burn patients, such as low blood pressure and decreased urine output