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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This choice is incorrect. Inability to read is not a finding that the nurse should expect in a client who has meningitis, but rather a possible finding in a client who has a stroke or a brain tumor. Meningitis does not affect the language or cognitive functions, but rather the meninges or the membranes that cover the brain and spinal cord.
Choice B Reason: This choice is incorrect. Bruising around the eyes is not a finding that the nurse should expect in a client who has meningitis, but rather a possible finding in a client who has a basilar skull fracture or a head trauma. Meningitis does not cause bleeding or bruising, but rather inflammation and infection of the meninges.
Choice C Reason: This is the correct choice. A throbbing headache is a finding that the nurse should expect in a client who has meningitis, as it is one of the most common and characteristic symptoms. A throbbing headache is caused by increased intracranial pressure and irritation of the meninges due to inflammation and infection.
Choice D Reason: This choice is incorrect. A heart rate of 50 is not a finding that the nurse should expect in a client who has meningitis, but rather a possible finding in a client who has bradycardia or a slow heart rate. Meningitis does not affect the heart rate, but rather the temperature and blood pressure. The nurse should expect to see fever and hypotension in a client who has meningitis.
Correct Answer is D
Explanation
Choice A Reason: Providing written materials and visual aids is not necessary for a client who has hearing at 15 dB, which is considered normal hearing. Normal hearing ranges from 0 to 20 dB, meaning that the person can hear sounds that are as faint as 20 dB or less.
Choice B Reason: Using American Sign Language is not appropriate for a client who has hearing at 15 dB, which is considered normal hearing. American Sign Language is a form of communication that uses hand gestures, facial expressions, and body movements to convey meaning. It is mainly used by people who are deaf or hard of hearing.
Choice C Reason: Shouting at the client from 6 inches away is not advisable for a client who has hearing at 15 dB, which is considered normal hearing. Shouting can be perceived as rude or aggressive, and can damage the hearing of both the speaker and the listener.
Choice D Reason: Speaking to the client in an everyday conversational tone is the best action for a client who has hearing at 15 dB, which is considered normal hearing. Conversational speech ranges from 40 to 60 dB, meaning that the person can hear sounds that are as loud as 60 dB or less.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.