The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands.
Which finding would the nurse expect to note in this condition?

Red skin with edema in the nail beds.

Black fingertips surrounded by an erythematous rash.

A white appearance to the skin that is insensitive to touch.

A pink edematous hand.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Red skin with edema in the nail beds is more indicative of a superficial injury or inflammation, such as cellulitis or a mild burn, rather than frostbite.

Choice B rationale

Black fingertips surrounded by an erythematous rash suggest gangrene or severe necrosis, which can occur in advanced stages of frostbite but is not an initial finding.

Choice C rationale

A white appearance to the skin that is insensitive to touch is a classic sign of frostbite. The lack of sensation is due to the freezing of tissues and nerves, and the white color indicates a lack of blood flow to the affected area.

Choice D rationale

A pink edematous hand is more indicative of a mild inflammatory response or early stages of frostbite before the tissue has frozen. It does not represent the more severe presentation of frostbite.

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Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale

A history of diabetes mellitus can cause delayed wound healing due to poor blood circulation and neuropathy, which can lead to reduced sensation and increased risk of infection.

Choice B rationale

A history of hyperlipidemia can contribute to delayed wound healing by causing atherosclerosis, which reduces blood flow to the wound site and impairs healing.

Choice C rationale

Wound infection is a direct cause of delayed wound healing. Infection can lead to increased inflammation, tissue damage, and prolonged healing time.

Choice D rationale

Decreased pedal perfusion indicates poor blood flow to the lower extremities, which can significantly delay wound healing by reducing the delivery of oxygen and nutrients to the wound.

Choice E rationale

Fasting blood glucose levels are important to monitor in patients with diabetes, as high glucose levels can impair the body’s ability to heal wounds effectively.

Correct Answer is ["72"]

Explanation

Step 1 is to calculate the burned area using the Rule of Nines. The Rule of Nines assigns percentages to different body areas to estimate the total body surface area (TBSA) affected by burns. For example, each arm is 9%, each leg is 18%, the front and back of the torso are each 18%, and the head is 9%.

Step 1: Calculate the burned area. If the client has burns on the front and back of both legs, the calculation would be: (18% + 18%) + (18% + 18%) = 72%

The final calculated answer is 72%.

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The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?

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Naxlex Comprehensive Predictor Exams

Select the 5 findings that can cause delayed wound healing.

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is admitting a client who has sustained severe burn injuries in a grease fire. Using the Rule of Nines, the nurse should estimate that the client has burned the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.

Correct Answer is ["72"]

Explanation

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A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.

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The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands.
Which finding would the nurse expect to note in this condition?