The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?
Superficial partial-thickness.
Full-thickness.
Deep partial-thickness.
Deep full-thickness.
The Correct Answer is B
Choice A rationale
A superficial partial-thickness burn involves the destruction of the epidermis and possibly a portion of the dermis. The description provided does not match this type of burn.
Choice B rationale
A full-thickness burn involves total destruction of the epidermis and dermis, and in some cases, the underlying tissue, muscle, and bone. The description of the burn as severely swollen, with a wound bed that appears brown and yellow, and the patient reporting no pain, is consistent with a full-thickness burn.
Choice C rationale
A deep partial-thickness burn involves the destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis. The description provided does not match this type of burn.
Choice D rationale
Deep full-thickness burns are a more severe form of full-thickness burns that extend beyond the dermis into deeper tissues. The description provided does not match this type of burn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While a white blood cell count can indicate an infection or inflammation in the body, it’s not the most relevant laboratory result to review when a client presents with petechiae and ecchymosis. These symptoms are more commonly associated with platelet disorders or coagulation issues.
Choice B rationale
A platelet count is the most relevant laboratory result to review for a client with petechiae and ecchymosis. These symptoms are often caused by low platelet counts, which can lead to bleeding and bruising. Therefore, reviewing the platelet count can provide valuable information about the client’s condition.
Choice C rationale
A red blood cell count can provide information about the client’s overall health and can indicate conditions like anemia. However, it’s not directly related to the presence of petechiae and ecchymosis.
Choice D rationale
Hemoglobin levels can indicate conditions like anemia, but they’re not directly related to the presence of petechiae and ecchymosis. These symptoms are more commonly associated with platelet disorders or coagulation issues.
Correct Answer is B
Explanation
Choice A rationale
While it’s important for patients with peripheral neuropathy to protect their feet, it’s recommended that they wear shoes at all times to prevent injury. Being barefoot, even inside the house, can increase the risk of foot injuries.
Choice B rationale
Regular foot exams are crucial for patients with peripheral neuropathy. Family members can assist with these exams, helping to identify any changes or injuries that may require medical attention.
Choice C rationale
Heating pads are not typically recommended for patients with peripheral neuropathy. Due to the loss of sensation in their feet, they may not realize if the pad is too hot, which could lead to burns.
Choice D rationale
Soaking feet in lukewarm water for extended periods is not typically recommended for patients with peripheral neuropathy. Prolonged exposure to water can dry out the skin and increase the risk of injury.
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