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 A

Explanation

"I should start trying to breastfeed within an hour of having my baby.” Choice A reason:

The client's statement indicates an understanding of the teaching because initiating breastfeeding within the first hour after birth is crucial for successful breastfeeding. This early initiation allows the baby to receive colostrum, which is rich in nutrients and antibodies, supporting the baby's immune system and providing essential nutrition during the initial stages of life. Additionally, early breastfeeding helps establish a strong bond between the mother and the baby while promoting the baby's suckling reflex.

Choice B reason:

The statement in Choice B is incorrect. Formula feeding between breastfeedings is not recommended in the early stages of breastfeeding, especially if the baby loses 5 percent of their birth weight. Newborns often lose some weight initially, which is normal, and it can be regained through effective breastfeeding. Supplementing with formula may interfere with establishing a good milk supply and the baby's ability to latch properly.

Choice C reason:

This statement in Choice C is incorrect. During breastfeeding sessions, it's essential for the baby to nurse on one breast fully before switching to the other breast. Allowing the baby to nurse for at least 10-15 minutes on each breast ensures they receive the hindmilk, which is higher in fat and essential for the baby's growth and development.

Choice D reason:

The statement in Choice D is incorrect. Offering a pacifier right after breastfeeding might interfere with the baby's feeding cues and lead to decreased breastfeeding frequency.

Newborns may suck for non-nutritive reasons, and offering a pacifier too soon can hinder proper breastfeeding establishment, as they may satisfy their sucking needs with the pacifier rather than nursing at the breast.

A. "I will discard insulin bottles 60 days after opening.”. B. "Before I exercise, I will need to take an extra 10 units of insulin.”. C. "If I feel dizzy, I will drink 4 ounces of orange juice.” D. "A hemoglobin A1c of 9 percent is a good goal."

Correct Answer is C

Explanation

Choice A reason:

The statement "I will discard insulin bottles 60 days after opening”. is incorrect. Insulin bottles typically have a shorter shelf life after opening, usually around 28 days. Discarding them after 60 days could lead to using ineffective insulin, which can be harmful to the individual's blood sugar control.

Choice B reason:

This statement is incorrect. Excessive insulin use can cause hypoglycemia which is aggravated by involvement in streneous exercise.

Choice C reason:

The statement "If I feel dizzy, I will drink 4 ounces of orange juice”. is correct. A feeling of dizziness is an early sign of hypoglycemia. Client should be encouraged to take simple acrbohydrayes when tehy experience any symptoms consistent with hypoglycemia

Choice D reason:

The statement "A hemoglobin A1c of 9 percent is a good goal”. is incorrect. Hemoglobin A1c reflects average blood sugar levels over the past 2-3 months. An A1c of 9 percent is relatively high and suggests poor diabetes management. The target A1c goal for most people with diabetes is typically below 7 percent, as recommended by the American Diabetes Association.

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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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