Author Question: The nurse is caring for a patient with frostbite. Which assessment findings would lead the nurse to ... (Read 119 times)

tsand2 · **on:** Jun 25, 2018

The nurse is caring for a patient with frostbite. Which assessment findings would lead the nurse to conclude that the patient has second-degree frostbite?

a. Reddened skin with hard white plaques
b. Waxy skin with sensory deficits
c. Reddened skin with milky fluid-filled blisters
d. Waxy skin with blood-filled blisters

Question 2

A student nurse is assisting with the care of a 50-year-old man who is being treated in the emergency department for hypothermia. The student asks the charge nurse why the patient is having his heart monitored. How should the nurse best respond?

a. Infusing intravenous (IV) fluids rapidly raise blood pressure (BP) and heart rate.
b. Adrenal output of epinephrine increases in response to cold stress.
c. Lactic acid from pooled blood in the ex-tremities shunts back to the heart.
d. The warming process causes vasodilation.

sierrahalpin · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

C
Frostbite is categorized by degree of injury, much like burns. Second-degree injury is characte-rized by redness, swelling, and formation of blisters filled with clear or milky fluid that forms within 24 hours of injury. A first-degree injury includes reddened skin, swelling, waxy appear-ance, hard white plaques, and sensory deficit. Third-degree injury consists of blood-filled blisters followed by black eschar forming over several weeks. Fourth-degree injury involves full-thickness damage affecting muscles, tendons, and bone, resulting in tissue loss.

Answer to Question 2

C
Lactic acid in the blood that was pooled in the extremities while being exposed to cold will shunt back to the heart through systemic perfusion as the warming process becomes effective. The lac-tic acid can cause arrhythmias.