A nurse reviews the following data in the chart of a patient with burn injuries: Based on the data provided, how would the nurse categorize this patients injuries?
Admission Notes: 36 y/o female with bilateral leg burns. NKFDA. Health history of asthma and seasonal allergies. Wound Assessment: Bilateral leg burns present with a white and leather Like appearance. No blisters or bleeding present. Patient rates pain 2/10 on a scale of 0 to 1 0
Full thickness
Superficial
Partial-thickness superficial
Partial-thickness deep
The Correct Answer is A
A. Full thickness:
Full-thickness burns involve damage to the entire thickness of the skin, including the epidermis and dermis. They often result in a white, charred, or leather-like appearance and are typically painless due to nerve damage. In the context of the patient's data, the description of "bilateral leg burns present with a white and leather-like appearance" indicates that the burns have penetrated deeply into the skin, suggesting full-thickness burns. The absence of blisters or bleeding is also consistent with full-thickness burns, as these burns often destroy the structures that would form blisters.
B. Superficial:
Superficial burns, also known as first-degree burns, only affect the outer layer of the skin (epidermis).They are characterized by redness, pain, and swelling but do not typically result in blisters or significant skin damage. The patient's description of "white and leather-like appearance" and the absence of blisters or bleeding are not indicative of superficial burns. Therefore, superficial burns are not an appropriate categorization based on the provided data.
C. Partial-thickness superficial:
Partial-thickness superficial burns, also known as second-degree superficial burns, affect the epidermis and part of the dermis. They are characterized by redness, blister formation, and pain. However, the description of "white and leather-like appearance" does not align with partial-thickness superficial burns, as these burns typically do not result in a white or charred appearance. Additionally, the absence of blisters or bleeding is not consistent with partial-thickness superficial burns.
D. Partial-thickness deep:
Partial-thickness deep burns, also known as second-degree deep burns, extend deeper into the dermis compared to partial-thickness superficial burns but do not penetrate through the entire dermis. They are characterized by redness, blister formation, and moderate to severe pain. The absence of blisters or bleeding and the description of "white and leather-like appearance" are more indicative of full-thickness burns rather than partial-thickness deep burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The transfusion will begin after the administration of 650 mg of acetaminophen (Tylenol).
This option suggests that the nurse would administer acetaminophen to lower the client's temperature and then proceed with the blood transfusion. While acetaminophen can be used to reduce fever, the decision to administer medication should be made by the healthcare provider after assessing the client's overall condition and determining the cause of the fever. Administering medication without proper evaluation and orders from the healthcare provider is not appropriate.
B. The blood will be held, and the health care provider will be notified.
This option is the correct choice. When a client has an elevated temperature before a blood transfusion, it is standard practice to hold the transfusion and notify the healthcare provider. An elevated temperature could indicate an underlying infection or another condition that needs to be evaluated before proceeding with the transfusion to ensure the client's safety.
C. The transfusion will begin after the administration of an antihistamine.
Administering an antihistamine would not be the appropriate action in response to an elevated temperature before a blood transfusion. Antihistamines are typically used to treat allergic reactions, not fevers. Holding the transfusion and notifying the healthcare provider to assess the situation would be the correct course of action.
D. The transfusion will begin as prescribed.
This option is not appropriate because starting the transfusion without addressing the elevated temperature could pose risks to the client's health. Elevated temperatures may indicate an underlying infection or other conditions that need to be evaluated before proceeding with the transfusion. Holding the transfusion and seeking further guidance from the healthcare provider is the recommended action in this scenario.
Correct Answer is ["B","C","E"]
Explanation
A. Healthy middle-aged adult who never had chickenpox:
This individual has not had chickenpox, which means they are susceptible to varicella-zoster virus (VZV) infection. If they contract herpes zoster (shingles), they are at risk for complications, although typically healthy adults are less likely to experience severe complications compared to immunocompromised individuals or older adults.
B. Older adult who takes large doses of prednisone for a chronic condition:
Chronic corticosteroid use, such as prednisone, can suppress the immune system and increase the risk of herpes zoster infection. Additionally, if herpes zoster develops in an older adult, they are at higher risk for complications such as postherpetic neuralgia (persistent nerve pain), bacterial superinfection of the rash, and dissemination of the virus.
C. Middle-aged adult who just started taking chemotherapy:
Chemotherapy suppresses the immune system, making individuals more susceptible to infections. If a person undergoing chemotherapy develops herpes zoster, they are at increased risk for serious complications due to their weakened immune response.
D. Nurse who recently received the first dose of varicella vaccine:
The varicella vaccine is designed to prevent chickenpox and reduce the risk of herpes zoster (shingles) in vaccinated individuals. Therefore, a nurse who received the varicella vaccine is less likely to experience serious complications from herpes zoster infection compared to those who are unvaccinated.
E. Young adult who is positive for the human immunodeficiency virus (HIV):
Individuals with HIV have a weakened immune system, increasing their susceptibility to infections, including herpes zoster. Moreover, herpes zoster in HIV-positive individuals can be more severe, prolonged, and may lead to complications such as disseminated herpes zoster, involving multiple organs and potentially becoming life-threatening.
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