Pediatrics EAQ Practice Exam - Practice Test, Questions and Study Guide

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Which of the following adverse responses should the nurse monitor for in a child with extensive burns?

Bradycardia

Disorientation

In a child with extensive burns, monitoring for disorientation is particularly crucial due to several factors associated with burn injuries. Extensive burns can lead to physiological stress that manifests in altered mental status, primarily due to hypovolemia, shock, or metabolic disturbances. As the body responds to the trauma of burns, it can lead to inadequate blood flow to the brain, resulting in confusion and disorientation.

Additionally, extensive burns can create a significant metabolic demand as the body tries to heal, increasing the risk of hypoxia and subsequent neurological effects. Therefore, observing for signs of disorientation can provide critical insight into the child's neurological status and may indicate the need for immediate medical intervention to address potential complications like shock or infection.

While other options might involve monitoring for potential changes in heart rate, blood pressure, or body temperature, they do not directly capture the level of consciousness and cognitive function that is so vital in assessing a child's overall condition following such traumatic injuries.

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Subnormal temperature

Systolic blood pressure of 100 mm Hg

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