A nurse is assisting with the care of an adolescent who has a partial-thickness burn. When observing the site of the burn, which of the following clinical manifestations should the nurse expect?
Brown in color.
Leathery appearance.
Visible ligaments.
Blister formation.
The Correct Answer is D
Choice A reason:
Brown in color. The rationale for this choice is that a partial-thickness burn involves damage to the epidermis and the dermis but not the full thickness of the skin. It typically presents with redness, swelling, and blisters. While the burned area may have some discoloration, it is more likely to be red or pink rather than brown. Brown coloration would suggest a deeper burn involving the full thickness of the skin and potentially underlying structures.
Choice B reason:
Leathery appearance. This choice is not expected in a partial-thickness burn. A leathery appearance is characteristic of a full-thickness (third-degree) burn, which involves the destruction of the epidermis, dermis, and potentially deeper tissues. In a partial-thickness burn, the skin may appear red, swollen, and blistered, but it should not have a leathery texture.
Choice C reason:
Visible ligaments. This choice is not indicative of a partial-thickness burn either. Partial- thickness burns primarily affect the epidermis and dermis, but they do not extend deep enough to expose ligaments or other structures below the skin. Visible ligaments would suggest a full-thickness burn or an injury that extends beyond the skin layers.
Choice D reason:
Blister formation. This is the correct choice. Blister formation is a common clinical manifestation of a partial-thickness burn. The injury causes fluid accumulation between the layers of the skin (epidermis and dermis), leading to the formation of blisters. The blisters may be filled with clear fluid and are usually painful and sensitive to touch.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C reason: The correct answer is choice C, "I need to use my levalbuterol inhaler before I exercise.” This statement indicates an understanding of the teaching because using the levalbuterol inhaler before exercise is a preventive measure for asthma symptoms. Levalbuterol is a short-acting beta-agonist that helps to relax the airway muscles and improve breathing. By using it before exercise, the client can prevent exercise-induced bronchoconstriction and reduce the risk of asthma symptoms during physical activity.
Choice A reason:
The statement "I will wait 15 seconds between puffs when using my levalbuterol inhaler” is incorrect. The recommended wait time between puffs of a levalbuterol inhaler is typically 30- 60 seconds to allow the medication to be fully absorbed and work effectively. Waiting only 15 seconds might not provide the desired therapeutic effect.
Choice B reason:
The statement "I need to use my fluticasone inhaler when I start to wheeze during exercise” is incorrect. Fluticasone is a corticosteroid inhaler used for long-term control of asthma symptoms, not for immediate relief during wheezing episodes. The client should use the fluticasone inhaler daily as prescribed to prevent asthma symptoms, including wheezing, from occurring in the first place.
Choice D reason:
The statement "I will stop using my fluticasone inhaler if I experience restlessness” is incorrect. Fluticasone is a long-term controller medication, and abruptly stopping it can lead to uncontrolled asthma symptoms and potentially exacerbate the condition. Restlessness might be a side effect of the medication, but it is not a reason to discontinue its use. If the client experiences any concerning side effects, they should consult their healthcare provider for appropriate management.
Correct Answer is D
Explanation
Choice A reason:
Insomnia may not be an expected finding in a school-age child with a newly diagnosed brain tumor. While sleep disturbances can occur due to various medical conditions, insomnia is not a common presenting symptom of brain tumors in this age group. Thus, it is less likely to be the correct answer.
Choice B reason:
A negative Babinski sign would actually be a normal finding in a school-age child. The Babinski sign is a neurological test that becomes positive in certain conditions, but a negative result is expected in a healthy child. Therefore, this finding is not indicative of a brain tumor and is not the correct choice.
Choice C reason:
Increased appetite is also an unlikely finding in a child with a newly diagnosed brain tumor. Brain tumors can lead to various neurological symptoms, but an increased appetite is not a characteristic feature. Thus, this choice is less likely to be correct.
Choice D reason:
Incoordination is a more expected finding in a school-age child with a newly diagnosed brain tumor. Brain tumors can affect motor skills and coordination due to their location and impact on the brain's functions. Children may experience difficulties with balance, coordination, and fine motor skills. Therefore, this choice is the most likely correct answer.
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