A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.)
Blisters
Wound blanches with pressure
Dry face
Intact epidermis
Sensitive to touch
Correct Answer : A,B,E
Choice A rationale: partial-thickness burns are usually characterized by the formation of blisters as a result of increased capillary permeability resulting in edema formation separating the epidermis from the dermis.
Choice B rationale: wound blanching with pressure is expected in partial-thickness burns due to compromised blood circulation.
Choice C rationale: This is not a typical finding in a partial-thickness burn.
Choice D rationale: this is incorrect since partial-thickness burns involve damage to the epidermis.
Choice E rationale: nerve endings are damaged in partial-thickness burns thus making the area sensitive to touch.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: pruritus is one of the symptoms of malignant melanoma, as well as changes in the shape, size, color, or texture of a mole or other skin lesion. However, pruritus is not specific to the disease and should always serve as a clue prompting further examination.
Choice B rationale: pain is a very rare symptom in malignant melanoma especially during the early stages of the disease. However, pain may occur in advanced stages of the disease when deeper tissues have been invaded and in cases of metastasis to distant sites.
Choice C rationale: purulent discharge is an indication of an underlying infection rather than malignant melanoma.
Choice D rationale: purplish skin discoloration is common in Kaposi’s sarcoma which manifests as purplish skin nodules rather than malignant melanoma. Furthermore, it may suggest bruising or bleeding under the skin. Malignant melanoma can have various colors, such as black, brown, red, blue, or white, depending on the type and amount of melanin produced by the tumor cells.
Correct Answer is B
Explanation
Choice A rationale: Rubbing the affected area may exacerbate pruritus and potentially spread scabies.
Choice B rationale: Providing mittens can prevent the client from scratching the affected areas, promoting healing and preventing the spread of scabies.
Choice C rationale: Hot water can worsen itching and should be avoided in scabies management.
Choice D rationale: The application of scabicide should follow the prescribed treatment plan, and additional application without guidance may lead to overuse and potential adverse effects.
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