On the first day post-burn, the body's fluid reserves have left ...

[laurencescou]

On the first day post-burn, the body's fluid reserves have left the circulating volume and entered the interstitial space, causing massive edema. The nurse monitors the burn victim very closely for:
 
  a. Increasing intracranial pressure
  b. Reduced urine output
  c. Eschar formation
  d. Fluid overload

Question 2

A child that had a shunt placed four years ago for hydrocephalus is in the emergency room complaining of a rapid onset of vomiting and increased lethargy. The nurse knows that the child will need:
 
  1. Nothing, as this is a normal complication and not an emergency.
   2. To be placed on IV fluids to help maintain an electrolyte balance.
   3. Small amounts of fluids until the vomiting has subsided.
   4. To consider this a neurological medical emergency and check the child's head circumference.

[HandsomeMarc]

Answer to Question 1

B
With the fluid loss, there will be less renal perfusion. The nurse should be alert for reduced urine output.

Answer to Question 2

4
Feedback
1. This should be considered a neurological emergency, and the child should be checked.
2. Electrolyte imbalances are more apt to occur when fluid is removed.
3. The history of having a shunt needs to be addressed first to prevent any neurological damage.
4. Measuring the head circumference will give an indication as to the amount of fluid not draining with the shunt and should be considered a medical emergency.

[laurencescou]

Excellent

[nyrave]

Gracias!