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 A
Explanation
The nurse should place the client on a low-sodium, fluid-restricted diet.
Acute glomerulonephritis is a kidney disease that can cause fluid retention and edema.
A low-sodium diet can help reduce fluid retention and swelling.
Fluid restriction can also help manage fluid balance and prevent further complications.
Choice B is not the best answer because a regular diet with no added salt may still contain high levels of sodium.
Choice C is not the best answer because a low-protein, low-potassium diet may not address the client’s fluid retention and edema.
Choice D is not the best answer because a low-carbohydrate, low-protein diet may not provide adequate nutrition for the client.
Correct Answer is B
Explanation
A.Allowing an infant with a cast for DDH to stand in the crib could place undue stress on the hips and may not be safe, depending on the type of cast and the stability of the condition. Most spica casts will not allow the child to stand, walk or bear any weight.
B.Providing a small electronic toy can help stimulate the infant's sensory and cognitive development. At 10 months old, infants are curious and responsive to interactive toys that can engage their senses and promote fine motor skills and cognitive development.
C.Tie colorful latex balloons to the side of the crib.: While colorful objects can be visually stimulating, latex balloons pose a choking hazard if they burst or are chewed on by the infant. It is safer to use other forms of visual stimulation, such as colorful toys or mobiles.
D.Change the infant's diaper as soon as soiling occurs.: While it is essential to keep the infant clean and dry to prevent skin irritation and infection, this action, although necessary, does not directly promote growth and development. It is a basic care measure rather than a developmental strategy.
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