A nurse is caring for a preschooler with a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.).
Intact epidermis.
Dry surface.
Sensitive to touch.
Wound blanches with pressure.
Blisters.
Correct Answer : C,D,E
The correct answers are C, D, and E.
Choice A rationale: Intact epidermis would not be expected with a partial-thickness burn as the burn extends into the dermis.
Choice B rationale: A dry surface is not characteristic of partial-thickness burns, which typically have a moist surface.
Choice C rationale: Partial-thickness burns are sensitive to touch due to the damage to nerve endings in the dermis.
Choice D rationale: Wound blanches with pressure because the blood vessels are damaged, allowing blanching on pressure.
Choice E rationale: Blisters are a common feature of partial-thickness burns, as the damage to the dermis causes fluid to accumulate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When determining that Bryant's traction is appropriately assembled, the nurse should observe that the buttocks is elevated slightly off of the bed.
In Bryant traction, both of the patient’s limbs are suspended in the air vertically at a ninety-degree angle from the hips and knees slightly flexed.
Choice A is incorrect because a padded sling is not used under the knee of the affected leg in Bryant traction.
Choice B is incorrect because skin straps are not used to maintain the leg in an
extended position in Bryant traction.
Choice C is incorrect because weights are not attached to a pin that is inserted into the femur in Bryant traction.
Correct Answer is D
Explanation
The nurse should first notify the provider about the bruises observed on the toddler.
Choice A is not correct because while it may be important to gather information from the parents, the nurse’s first action should be to notify the provider.
Choice B is not correct because while it may be important to gather information from the toddler, the nurse’s first action should be to notify the provider.
Choice C is not correct because while notifying social services may be necessary in some cases, the nurse’s first action should be to notify the provider.
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