A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hours ago. Which of the following findings should the nurse expect?

Epithelialization at the site

Severe pain at the site

Edema at the site

Blistering at the site

Answer and Explanation

The Correct Answer is C

Choice A reason: Epithelialization at the site of a major full-thickness burn would not be expected 12 hours post-injury. Epithelialization is a later stage of wound healing where new skin cells form and cover the wound. In full-thickness burns, this process is significantly delayed and typically requires skin grafting for wound closure.

Choice B reason: Severe pain is not typically associated with full-thickness burns due to the destruction of nerve endings in the skin. However, there may be severe pain in the surrounding areas that have sustained less severe burns.

Choice C reason: Edema is a common and expected finding at the site of a major full-thickness burn 12 hours post-injury. The inflammatory response to the burn injury leads to increased vascular permeability and fluid shift from the intravascular to the interstitial space, resulting in edema.

Choice D reason: Blistering is characteristic of partial-thickness burns (second-degree burns) but not full-thickness burns (third-degree burns). In full-thickness burns, the skin is destroyed to the point where blisters do not form.

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Correct Answer is A

Explanation

Choice A reason: This statement encourages the client's involvement by offering assistance in creating a personalized list of preferred foods, which can then be discussed with the dietitian. It promotes a collaborative approach to the dietary plan, allowing the client to have a say in their food choices, which is essential for long-term adherence and management of type 2 diabetes.

Choice B reason: While this statement shows empathy, it does not actively encourage the client's involvement in their care. Understanding the challenges is important, but it is more beneficial to empower the client to take an active role in managing their dietary choices.

Choice C reason: This statement is factual, as managing diabetes does require accommodations. However, it does not directly encourage the client's involvement. Instead, it could be more encouraging by suggesting ways the client can participate in making those accommodations.

Choice D reason: Informing the client that the dietitian will provide the best food choices is reassuring but does not facilitate the client's involvement. It positions the dietitian as the sole decision-maker rather than including the client as an active participant in their dietary planning.

A. Petechiae on the chest B. Bradycardia C. Intermittent headache D. Photophobia

Correct Answer is D

Explanation

Choice A reason: Petechiae on the chest are small, red or purple spots caused by bleeding into the skin and may be associated with various conditions, including infections. However, they are not a common finding in meningitis. Meningitis typically presents with symptoms related to inflammation of the meninges, the protective membranes covering the brain and spinal cord.

Choice B reason: Bradycardia, which is a slower than normal heart rate, is not a typical symptom of meningitis. While meningitis can affect various bodily functions, the classic symptoms are fever, headache, and neck stiffness, not changes in heart rate.

Choice C reason: Intermittent headache could be associated with meningitis, but the headaches that accompany meningitis are usually constant and severe due to the inflammation of the meninges. They are not typically described as intermittent.

Choice D reason: Photophobia, or light sensitivity, is a common finding in meningitis. The inflammation of the meninges can lead to an increased sensitivity to light, causing discomfort or pain when the patient is exposed to bright lights. This symptom, along with headache, neck stiffness, and fever, helps to distinguish meningitis from other conditions.

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A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hours ago. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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