A client presents to the emergency department in severe pain and reports that a pot of boiling water accidentally spilled on his lower legs.
The assessment reveals soft and dry eschar, mottled red skin, and moderately edematous feet. Which depth of burn should the nurse document?

First degree.

Deep partial thickness.

Superficial partial thickness.

Full thickness.

Answer and Explanation

The Correct Answer is B

Understanding the clinical presentation of thermal injuries is necessary to categorize burn depth accurately. This requires knowledge of integumentary layers, including the epidermis, dermis, and subcutaneous tissues, and how specific visual markers like eschar or mottling reflect the level of tissue destruction.

Choice A rationale

First degree burns, or superficial burns, involve only the epidermis. They are characterized by redness, pain, and mild edema without blistering or eschar. The skin remains intact and dry, unlike the mottled red skin and edema seen here.

Choice B rationale

Deep partial thickness burns extend into the deeper layers of the dermis. Findings include a mottled red appearance, moderate edema, and soft, dry eschar. These wounds take longer to heal and usually require surgical intervention for optimal recovery.

Choice C rationale

Superficial partial thickness burns involve the epidermis and upper dermis. They typically present with pink, moist skin and blister formation. The presence of soft eschar and mottled red skin indicates a deeper injury than what is characteristic here.

Choice D rationale

Full thickness burns involve the entire dermis and may reach subcutaneous fat or muscle. The skin appears waxy white, leathery, or charred. While eschar is present, it is usually hard and inelastic rather than soft and mottled.

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Correct Answer is A

Explanation

Pancreatitis often leads to electrolyte imbalances, specifically hypocalcemia due to fat necrosis and soap formation. Knowledge of cardiac electrophysiology is required to recognize how low calcium levels (normal 8.5 to 10.5 mg/dL) affect the myocardial action potential.

Choice A rationale

Prolonged QT interval is a classic electrocardiogram finding in hypocalcemia. Low serum calcium slows the movement of calcium into the cardiac cells during the plateau phase, thereby lengthening the duration of ventricular depolarization and repolarization cycles.

Choice B rationale

A shortened PR interval is not associated with hypocalcemia. PR interval changes are more frequently linked to pre-excitation syndromes or inflammatory conditions of the heart, rather than the specific electrolyte shifts seen in acute pancreatic inflammation.

Choice C rationale

Peaked T waves are a hallmark sign of hyperkalemia, not hypocalcemia. In hypocalcemia, the T wave may actually appear flattened or inverted, but the most distinctive and supportive finding remains the elongation of the QT interval.

Choice D rationale

Elevated ST segments are typically indicative of myocardial infarction or pericarditis. While electrolyte imbalances can cause various cardiac changes, ST elevation is not the primary diagnostic indicator used to support a suspicion of clinical hypocalcemia.

A. Administer a loop diuretic. B. Administer furosemide. C. Initiate hemodialysis. D. Increase fluid intake.

Correct Answer is C

Explanation

Managing electrolyte imbalances in end stage renal disease requires understanding renal excretion failures. The presence of cardiac rhythm changes indicates a life threatening emergency. Immediate intervention is necessary to remove toxins and excess ions that the kidneys cannot process.

Choice A rationale

Loop diuretics are ineffective for clients with end stage renal disease because the nephrons are no longer functional. These medications cannot induce diuresis or lower serum potassium levels when the kidneys have reached the point of failure.

Choice B rationale

Similar to other loop diuretics, furosemide relies on renal blood flow and functional kidney tissue to promote fluid and electrolyte excretion. In end stage failure, this medication will not resolve the cardiac symptoms or hyperkalemia.

Choice C rationale

This is the definitive treatment for life threatening hyperkalemia in renal failure. Dialysis rapidly removes excess potassium and metabolic waste from the blood. It corrects the electrical instability in the heart caused by the high potassium levels.

Choice D rationale

Increasing fluid intake is contraindicated in end stage renal disease due to the risk of fluid volume overload. This would exacerbate the client's condition, potentially leading to pulmonary edema, hypertension, and worsening of the cardiac strain.

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A client presents to the emergency department in severe pain and reports that a pot of boiling water accidentally spilled on his lower legs. The assessment reveals soft and dry eschar, mottled red skin, and moderately edematous feet. Which depth of burn should the nurse document?

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Naxlex Comprehensive Predictor Exams

The nurse suspects that a client with pancreatitis has developed hypocalcemia. Which electrocardiogram finding supports the nurse's suspicion?

Correct Answer is A

Explanation

A client with end stage renal disease presents to the emergency department with severe fatigue, palpitations, and muscle weakness. The electrocardiogram reveals peaked T waves and a widened QRS complex. Which treatment should the nurse anticipate?

Correct Answer is C

Explanation

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An adult weighing 88 kg is brought to the emergency department after sustaining a thermal injury. Burns are partial and full thickness over 38 According to the Parkland formula, what would this client's fluid requirements be for the first 24 hours after injury?

A client presents to the emergency department in severe pain and reports that a pot of boiling water accidentally spilled on his lower legs.
The assessment reveals soft and dry eschar, mottled red skin, and moderately edematous feet. Which depth of burn should the nurse document?