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 C
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: The burned area is pink in color with blisters present is a finding of a deep partial-thickness burn, which involves the epidermis and most of the dermis, causing severe pain, blanching, mottling, and blistering.
Choice D Reason: The burned area is red in color with soft eschar present is not a finding of a deep partial-thickness burn, but a superficial full-thickness burn. A superficial full-thickness burn involves the epidermis and dermis, causing dryness, whiteness or redness, and soft or waxy eschar.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because standing directly in front of the client is not the priority action by the nurse when admitting a client who has a partial hearing loss. Standing directly in front of the client can enhance communication, but it is not as important as assessing the client's hearing status and needs.
Choice B Reason: This is incorrect because rephrasing statements the client does not hear is not the priority action by the nurse when admitting a client who has a partial hearing loss. Rephrasing statements can improve understanding, but it is not as essential as evaluating the client's hearing level and preferences.
Choice C Reason: This is incorrect because speaking using his usual tone of voice is not the priority action by the nurse when admitting a client who has a partial hearing loss. Speaking using his usual tone of voice may or may not be appropriate, depending on the client's hearing ability and comfort. The nurse should adjust his tone of voice based on the client's feedback and response.
Choice D Reason: This is the correct choice because determining if the client uses hearing aids is the priority action by the nurse when admitting a client who has a partial hearing loss. Hearing aids are devices that amplify sound and improve hearing for people with hearing loss. The nurse should determine if the client uses hearing aids, and if so, check their function, fit, and battery life. The nurse should also ask about any other assistive devices or strategies that the client uses to communicate effectively.
Correct Answer is D
Explanation
Choice A reason: Resting in bed for at least 2 days is not necessary after cataract surgery. The client should resume normal activities as soon as possible, but avoid strenuous activities that increase intraocular pressure.
Choice B reason: Deep breathing and coughing four times a day are not related to cataract surgery. This is a technique to prevent respiratory complications after abdominal or thoracic surgery.
Choice C reason: After two days, a creamy discharge is not normal. This could indicate an infection or inflammation of the eye. The client should report any changes in vision, pain, redness, swelling, or discharge to the provider.
Choice D reason: Keeping the head up and straight is the correct instruction. This helps to prevent increased intraocular pressure and bleeding in the eye. The client should also avoid rubbing or touching the eye, wearing sunglasses to protect from bright light, and using prescribed eye drops as directed.
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.