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 ["C","E","F"]

Explanation

Choice A reason: This is incorrect because the nurse should not include this in the postoperative education to the client. The client should not drive home after glaucoma surgery, as they will have reduced vision and increased sensitivity to light in the operated eye. The nurse should advise the client to arrange for someone else to drive them home.

Choice B reason: This is incorrect because the nurse should not include this in the postoperative education to the client. The client should not lay on the right side when going to bed, as this can put pressure on the operated eye and increase the risk of bleeding or infection. The nurse should advise the client to sleep on their back or on their left side.

Choice C reason: This is correct because the nurse should include this in the postoperative education to the client. The client should report flashing lights, as this can indicate a complication such as retinal detachment or vitreous hemorrhage. The nurse should instruct the client to call the provider immediately if they see flashing lights.

Choice D reason: This is incorrect because the nurse should not include this in the postoperative education to the client. The client should not nap on their left side when they get home, as this can cause fluid accumulation and increased intraocular pressure in the operated eye. The nurse should advise the client to elevate their head at least 30 degrees when resting.

Choice E reason: This is correct because the nurse should include this in the postoperative education to
the client. The client should avoid housework like vacuuming, as this can cause bending, lifting, or straining that can increase intraocular pressure and affect wound healing. The nurse should advise the client to limit physical activity and follow the provider's instructions on when to resume normal activities.

Choice F reason: This is correct because the nurse should include this in the postoperative education to
the client. The client may see flashes of light in the operated eye, as this is a normal phenomenon caused by stimulation of the retina by gas bubbles or fluid shifts. The nurse should reassure the client that flashes of light are normal and will subside over time.

A. The test is inconclusive B. The client has conductive hearing loss C. The client has normal hearing D. The client has sensorineural hearing loss

Correct Answer is B

Explanation

Choice A Reason: The test is not inconclusive, but rather positive for conductive hearing loss. The Weber test involves placing a vibrating tuning fork on the center of the forehead and asking the client which ear hears the sound louder. It can help differentiate between conductive and sensorineural hearing loss.

Choice B Reason: This is the correct choice. The client has conductive hearing loss, which is a type of hearing loss that occurs when sound waves are blocked or reduced in the outer or middle ear. It can be caused by earwax, infection, fluid, perforation, or trauma. In conductive hearing loss, the Weber test shows lateralization to the affected ear, meaning the sound is heard louder in that ear.

Choice C Reason: The client does not have normal hearing, but rather conductive hearing loss. In normal hearing, the Weber test shows no lateralization, meaning the sound is heard equally in both ears.

Choice D Reason: The client does not have sensorineural hearing loss, but rather conductive hearing loss. Sensorineural hearing loss is a type of hearing loss that occurs when there is damage to the inner ear or auditory nerve. It can be caused by aging, noise exposure, disease, or drugs. In sensorineural hearing loss, the Weber test shows lateralization to the unaffected ear, meaning the sound is heard louder in that ear.

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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 is postoperative from glaucoma surgery in the right eye. Which of the following will the nurse include in the postoperative education to the client? (Select all that apply.)

Correct Answer is ["C","E","F"]

Explanation

A nurse is performing a Weber test on a client who reports difficulty hearing in his left ear. The client informs the nurse that he can hear the tone louder in his left ear. Which of the following does this result indicate?

Correct Answer is B

Explanation

A nurse is caring for a client who has suffered a stroke involving the left hemisphere. Which of the following alterations in function are consistent with this type of stroke?

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (Select all that apply.)

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns on the head, neck, and chest. The nurse should identify which of the following risks is the priority for assessment and intervention.

A client arrives with an upper respiratory infection and complains of otalgia, malaise, and nasal drainage. The client's temperature is 100.7 F. Which of the following will the nurse anticipate providing to the client?

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?