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 C
Explanation
Choice A rationale: Hemoglobin level reflects the oxygen-carrying capacity of the blood but is not a direct indicator of nutritional status.
Choice B rationale: International Normalized Ratio (INR) is a measure of blood clotting, and a normal value does not directly impact wound healing.
Choice C rationale: Serum albumin is a marker of nutritional status, and a low level (hypoalbuminemia) can adversely affect wound healing. Adequate protein intake is essential for collagen synthesis and overall tissue repair.
Choice D rationale: White blood cell count is an indicator of immune response and infection but does not directly affect wound healing in the absence of infection.
Correct Answer is A
Explanation
Choice A rationale: Phototherapy can sometimes cause sensitivity to light, and wearing dark glasses can help protect the eyes from excessive light exposure.
Choice B rationale: It is not typical to interrupt phototherapy due to redness and tenderness, as some skin reactions may occur during treatment but can be managed without interruption.
Choice C rationale: The schedule of phototherapy can vary, and the choice of days on and off may not necessarily be fixed in a three-day pattern.
Choice D rationale: The frequency and timing of phototherapy sessions depend on the specific treatment plan prescribed by the healthcare provider.
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