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?

The burned area is yellow in color with severe edema.

The burned area is black in color and pain is absent.

The burned area is pink in color with blisters present.

The burned area is red in color with soft eschar present.

Answer and Explanation

The Correct Answer is D

Choice A Reason: The burned area is yellow in color with severe edema is not a finding of a deep partial-thickness burn, but a superficial partial-thickness burn. A superficial partial-thickness burn involves the epidermis and the upper layer of the dermis, causing pain, redness, swelling, and blistering.

Choice B Reason: The burned area is black in color and pain is absent is not a finding of a deep partial-thickness burn, but a full-thickness burn. A full-thickness burn involves the epidermis, dermis, and underlying tissues, causing necrosis, charred skin, and loss of sensation.

Choice C Reason: This description aligns with a superficial partial-thickness (first-degree or mild second-degree) burn rather than a deep partial-thickness burn. Superficial partial-thickness burns involve the epidermis and the upper portion of the dermis. These burns appear pink or red, often accompanied by moisture and blister formation due to fluid leakage from damaged capillaries. They are painful because nerve endings remain intact. Healing occurs within 10 to 21 days without significant scarring.

Choice D Reason: Deep partial-thickness burns extend deeper into the dermis, damaging a larger portion of skin structures, including sweat glands and hair follicles. These burns typically appear red or white and may have a soft eschar (dead tissue), which differentiates them from more superficial burns that do not develop eschar. Unlike full-thickness burns, nerve endings remain partially intact, so the patient may still experience some pain. These burns take more than 21 days to heal and often require skin grafting to prevent complications such as contractures or hypertrophic scarring.

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Correct Answer is C

Explanation

Choice A Reason: Educating the client about the therapy is an important action by the nurse, but not the priority one. The nurse should explain the purpose, procedure, benefits, and risks of hydrotherapy to the client before starting it, but only after ensuring their comfort and pain relief.

Choice B Reason: Providing analgesics after therapy ends is not enough, as the nurse should provide them before and during therapy as well. Hydrotherapy involves cleansing and debriding of burn wounds with water jets or whirlpools, which can be very painful and stressful for the client.

Choice C Reason: This is the correct choice. Providing analgesics before therapy begins is the priority action by the nurse, as it reduces pain and anxiety for the client and facilitates wound healing. The nurse should assess the client's pain level and administer appropriate analgesics at least 30 minutes before hydrotherapy.

Choice D Reason: Ensuring there are clean supplies is an essential action by the nurse, but not the priority one. The nurse should use sterile or clean equipment and solutions for hydrotherapy to prevent infection and contamination of burn wounds, but only after ensuring their comfort and pain relief.

A. The test assesses for sun protection factor B. The test is inconclusive C. The presence of erythema indicates you are allergic to the allergen D. The areas that did not turn red indicate low risk for skin cancer

Correct Answer is C

Explanation

Choice A Reason: The test does not assess for sun protection factor, but rather for contact dermatitis. Sun protection factor is a measure of how well a sunscreen protects the skin from ultraviolet radiation, which can cause sunburn and skin damage.

Choice B Reason: The test is not inconclusive, but rather positive for some allergens and negative for others. The test involves applying small patches of different substances to the skin and observing for any reactions after 48 hours.

Choice C Reason: This is the correct choice. The presence of erythema indicates you are allergic to the allergen, as it shows inflammation and irritation of the skin due to an immune response. Erythema is redness of the skin that can be accompanied by itching, swelling, or blisters.

Choice D Reason: The areas that did not turn red do not indicate low risk for skin cancer, but rather no reaction to the allergen. Skin cancer is a malignant growth of abnormal cells in the skin that can be caused by various factors, such as genetic mutations, exposure to carcinogens, or immunosuppression.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client with extensive burns for hydrotherapy. What is the priority action by the nurse?

Correct Answer is C

Explanation

A client has a patch test performed with the following results. Which of the following is the best response the nurse will offer the client regarding the observations from the test?

Correct Answer is C

Explanation

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