A client arrives to the clinic after spending the day at the beach. She reports extreme pain and the nurse observes red skin on her face and upper body. There are no blisters present. What degree of burn has the client suffered?

First degree

Second degree

Third degree

This burn cannot be classified

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is correct because first degree burns are superficial burns that affect only the outer layer of the skin, called the epidermis. First degree burns cause redness, pain, and mild swelling, but no blisters or scarring. They usually heal within a week.

Choice B Reason: This is incorrect because second degree burns are partial thickness burns that affect both the epidermis and the underlying layer of the skin, called the dermis. Second degree burns cause blisters, severe pain, and possible infection. They may take several weeks to heal and may leave scars.

Choice C Reason: This is incorrect because third degree burns are full thickness burns that destroy all layers of the skin and may damage the underlying tissues, such as muscles, nerves, or bones. Third degree burns cause charred or white skin, numbness, and shock. They require skin grafting and may cause permanent disability or death.

Choice D Reason: This is incorrect because this burn can be classified according to the depth and extent of the skin damage. The classification of burns helps to determine the appropriate treatment and prognosis for the client.

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Correct Answer is D

Explanation

Choice A Reason: A heart rate of 122/min is elevated, but not life-threatening. It could be due to pain, anxiety, dehydration, or infection.

Choice B Reason: A urinary output of 25 ml/hr is low, but not critical. It could indicate fluid loss, kidney damage, or inadequate fluid resuscitation.

Choice C Reason: A pain level of 6 on a scale of 0 to 10 is moderate, but not severe. It could be managed with analgesics and non-pharmacological interventions.

Choice D Reason: This is the correct answer because difficulty swallowing can indicate airway obstruction, inhalation injury, or edema of the throat. It can compromise breathing and require immediate intervention.

A. Measure the abdominal girth B. Have the client extend their arms C. Have the client flex and extend their foot D. Ask the client to walk heel to toe

Correct Answer is B

Explanation

Choice A Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis.

Choice B Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease.

Choice C Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy.

Choice D Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.

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A client arrives to the clinic after spending the day at the beach. She reports extreme pain and the nurse observes red skin on her face and upper body. There are no blisters present. What degree of burn has the client suffered?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Correct Answer is D

Explanation

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Correct Answer is B

Explanation

A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?

A client arrives to the clinic with reports of progressive weakness in his lower extremities. Which of the following findings in the client's history is consistent with the client developing Guillain-Barre syndrome?

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A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?

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A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments?

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