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 D
Explanation
Choice A reason:
The nurse should not remind the client to void every 4 hours because epidural anesthesia can cause temporary loss of bladder sensation, making it difficult for the client to know when to void. Instead, the nurse should use a bladder scanner to assess for urinary retention and encourage the client to void regularly.
Choice B reason:
Encouraging the client to alternate from side to side every 2 hours is not directly related to the administration of epidural anesthesia. This action is commonly advised for clients who are on bed rest to prevent pressure ulcers and promote circulation. However, it is not specifically necessary for the client receiving epidural anesthesia for pain management during labor.
Choice C reason:
Raising the four side rails on the client's bed is not necessary in this situation. The use of side rails should be based on the client's mobility and risk assessment for falls. If the client is receiving epidural anesthesia, they may experience reduced mobility, but the decision to use side rails should be made on an individual basis, not solely based on the anesthesia.
Choice D reason:
Monitoring the client's blood pressure is a crucial action when a client is receiving epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, leading to hypotension. By regularly monitoring the client's blood pressure, the nurse can detect any significant changes and take appropriate actions to maintain hemodynamic stability.
Correct Answer is B
Explanation
Choice A reason:
One cup of oatmeal - Oatmeal is a nutritious food, but it does not contain as high a protein content as some other options. While it offers some protein, it is not the best choice for a high-protein diet during pregnancy. Oatmeal is primarily known for its fiber content and complex carbohydrates, which provide sustained energy.
Choice B reason:
One cup of tofu - Tofu is an excellent source of protein and is a suitable choice for a high- protein diet during pregnancy. Tofu is made from soybeans and is rich in plant-based proteins, making it an ideal option for individuals following a vegetarian or vegan diet as well. Additionally, tofu contains essential amino acids, iron, calcium, and other nutrients beneficial for both the mother and the developing fetus.
Choice C reason:
One cup of brown rice - While brown rice is a healthy whole grain and provides some protein, it does not have as high a protein content as tofu. Brown rice is a good source of complex carbohydrates, fiber, vitamins, and minerals, but it may not meet the high protein requirements of a pregnant woman's diet.
Choice D reason:
One cup of kale - Kale is a nutritious leafy green vegetable, but it does not offer a significant amount of protein compared to tofu. It is rich in vitamins, minerals, and antioxidants, making it a valuable addition to a balanced diet. However, for a high-protein diet during pregnancy, other options like tofu are more suitable.
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