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.

Answer and Explanation

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.

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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.

A. "I should add 500 calories per day to my diet.” B. "I will use antibacterial soap and warm water to wash my breasts.” C. "Breastfeeding is a reliable method of birth control.” D. "If my nipples become cracked and red, I will apply hydrocortisone cream.”

Correct Answer is B

Explanation

Choice A reason:

The client stating, "I should add 500 calories per day to my diet,” is not an accurate understanding of breastfeeding. While it is true that breastfeeding mothers require additional calories to support lactation, the specific amount of calories needed varies depending on individual factors and should be discussed with a healthcare professional. Simply adding 500 calories per day may not be appropriate for every woman and could lead to excessive weight gain.

Choice B reason:

This choice indicates an understanding of proper breast hygiene during breastfeeding. Using antibacterial soap and warm water to wash the breasts helps to prevent infection and maintain good breast health, reducing the risk of complications for both the mother and the baby.

Choice C reason:

The statement, "Breastfeeding is a reliable method of birth control,” is incorrect. While breastfeeding can provide some natural contraceptive effects, it is not a foolproof method of birth control. This concept is known as the lactational amenorrhea method (LAM), and specific criteria must be met for it to be considered a reliable form of contraception. Relying solely on breastfeeding as birth control can lead to an unintended pregnancy.

Choice D reason:

The statement, "If my nipples become cracked and red, I will apply hydrocortisone cream,” is not advisable. While hydrocortisone cream may provide temporary relief from irritation, it is not recommended for breastfeeding mothers. Ingestion of the cream by the baby can be harmful. Instead, the client should seek guidance from a healthcare professional to address and resolve any breastfeeding-related nipple issues.

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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?

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