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 A
Explanation
Abdominal distention. Choice A reason:
Abdominal distention is a common manifestation of Hirschsprung's disease in infants. This condition is characterized by the absence of ganglion cells in the distal segment of the colon, leading to a functional obstruction. The absence of ganglion cells causes the affected part of the colon to become narrow and unable to relax, resulting in a buildup of stool and gas, leading to abdominal distention.
Choice B reason:
Steatorrhea, which is the presence of fatty, bulky, and foul-smelling stools, is not typically associated with Hirschsprung's disease. This manifestation is more commonly seen in conditions affecting the pancreas, liver, or small intestine, where the digestion and absorption of fats are impaired.
Choice C reason:
Blood-tinged emesis (vomiting) is not a typical manifestation of Hirschsprung's disease. This symptom is more commonly associated with gastrointestinal bleeding, which can be caused by various factors such as ulcers, esophageal varices, or gastritis.
Choice D reason:
Dysphagia, which refers to difficulty swallowing, is also not a characteristic manifestation of Hirschsprung's disease. Dysphagia is more commonly seen in conditions affecting the esophagus or throat, such as esophageal strictures or neurological disorders affecting swallowing reflexes.
Correct Answer is D
Explanation
Choice A reason:
Take this medication every day for regular bowel movements. Rationale: This choice is incorrect. Docusate sodium is a stool softener used to prevent constipation, but it should not be taken daily for regular bowel movements. Overuse of stool softeners can lead to dependence and may disrupt the natural bowel function.
Choice B reason:
Take the medication with mineral oil. Rationale: This choice is incorrect. Docusate sodium should not be taken with mineral oil. When taken together, they can form a mixture that is difficult for the body to absorb, leading to potential adverse effects.
Choice C reason:
Decrease dietary fiber intake while taking this medication. Rationale: This choice is incorrect. It is not advisable to decrease dietary fiber intake while taking docusate sodium. Fiber is essential for promoting regular bowel movements and overall gastrointestinal health.
Combining the medication with a high-fiber diet can enhance its effectiveness.
Choice D reason:
Take the medication with a full glass of water. Rationale: This choice is correct. The nurse should instruct the client to take docusate sodium with a full glass of water. The water helps to soften the stool and allows the medication to work effectively in preventing constipation.
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