A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site?
Erythema
Eschar
Blistering
Absence of pain
The Correct Answer is A
Choice A rationale: Erythema (redness) is the first indication of a superficial burn injury. Superficial burns, also known as first-degree burns, involve only the outer layer of the skin and are characterized by redness without blistering.
Choice B rationale: Eschar is associated with deeper burns and is not the first indication of a superficial burn.
Choice C rationale: Blistering is associated with partial-thickness burns (second-degree burns) and does not occur in superficial burns.
Choice D rationale: Pain is typically present in superficial burns, and the absence of pain is not a characteristic of superficial burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale: Hyperlipidemia, particularly elevated cholesterol levels, can be associated with impaired wound healing. High cholesterol levels can contribute to atherosclerosis, leading to reduced blood flow to the wound site. Adequate blood supply is crucial for delivering oxygen and nutrients essential for the healing process.
Choice B rationale: Diabetes mellitus is a well-known risk factor for delayed wound healing. High blood sugar levels can impair the function of white blood cells, reduce collagen formation, and impair the overall healing process. Furthermore, individuals with diabetes are more prone to infections and may experience slower wound closure.
Choice C rationale: Medication history alone does not provide specific information about factors that directly affect wound healing. However, certain medications, such as corticosteroids or immunosuppressive drugs, may impact the healing process.
Choice D rationale: High cholesterol levels can contribute to atherosclerosis, leading to reduced blood flow to the wound site. Adequate blood supply is crucial for delivering oxygen and nutrients essential for the healing process.
Choice E rationale: Prealbumin is a marker of protein status and nutritional adequacy. Low prealbumin levels can indicate malnutrition, which is a risk factor for delayed wound healing. Adequate protein intake is crucial for collagen synthesis and overall tissue repair.
Correct Answer is A
Explanation
Choice A rationale: Transparent dressings are commonly used for stage I pressure ulcers as they provide a protective barrier against external contaminants while allowing for visualization of the wound. This type of dressing helps maintain a moist environment to facilitate healing.
Choice B rationale: Hydrogel dressings are typically used for wounds with necrotic tissue or those that require a moist environment. They may not be the first choice for a stage I pressure ulcer with intact skin.
Choice C rationale: Wet-to-dry dressings are often used for wounds with debris or infection. They involve placing moist gauze into the wound and allowing it to dry, promoting debridement. This is not suitable for an intact stage I pressure ulcer.
Choice D rationale: Alginate dressings are absorbent and are more appropriate for wounds with moderate to heavy exudate. They may not be necessary for a stage I pressure ulcer with minimal or no exudate.
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