A client is being evaluated in the emergency department after ...

[Yi-Chen]

A client is being evaluated in the emergency department after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas.
 
  Which of the following best describes the underlying cause for this manifestation? 1. Reduced vascular permeability at the site of the burned area
   2. Decreased osmotic pressure in the burned tissue
   3. Increased fluids in the extracellular compartment
   4. Inability of the damaged capillaries to maintain fluids in the cell walls

Question 2

During assessment of the patient with pneumonia, the nurse notes a bluish coloration of the skin. The nurse interprets this to mean the patient is
 
  a. in the early stages of a respiratory problem
  b. improving
  c. hypoxic
  d. hyperventilating

[mk6555]

Answer to Question 1

4. Inability of the damaged capillaries to maintain fluids in the cell walls

Rationale:
Burn shock occurs during the first 2436 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments.

Answer to Question 2

C
Cyanosis is often a late sign in patients with poor oxygenation. The presence of cyanosis is considered as an indicator of a hypoxic emergency. Hypoxia can lead to a decrease in respiratory rate.