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
Using an incentive spirometer is generally recommended for respiratory conditions to improve lung function, not specifically for a client with hydronephrosis and a history of renal calculi.
Choice B rationale
Monitoring the urinary stream for decreased output is crucial for a client with hydronephrosis and a history of renal calculi. Hydronephrosis is a condition characterized by urine accumulation in the kidney, which can lead to decreased urine output. Therefore, monitoring urinary output can help detect any potential complications or worsening of the condition.
Choice C rationale
Restricting physical activities is not typically necessary for a client with hydronephrosis and a history of renal calculi unless specified by the healthcare provider. It’s more important to focus on maintaining overall health and well-being.
Choice D rationale
Reporting when hematuria becomes pink-tinged is not the most relevant instruction for a client with hydronephrosis and a history of renal calculi. While it’s important to report any changes in urine color, monitoring urinary output (Choice B) is more directly related to the client’s condition.
Correct Answer is A
Explanation
Choice A rationale
As with, a lumbar puncture is the primary diagnostic procedure for suspected bacterial meningitis. The other choices, while useful for detecting other conditions, are not as definitive for diagnosing bacterial meningitis.
Choice B rationale
As mentioned in the rationale for, Choice B, skull radiography is not typically used to diagnose bacterial meningitis.
Choice C rationale
As mentioned in the rationale for, Choice C, an MRI can provide detailed images of the brain and surrounding tissues, but it is not the primary tool for diagnosing bacterial meningitis.
Choice D rationale
As mentioned in the rationale for, Choice D, a CT scan can detect abnormalities in the brain, but it cannot definitively diagnose bacterial meningitis.
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