A 5-year-old child is admitted to the emergency department with partial-thickness burns covering the face and neck after a kitchen accident.
Which assessment should the nurse prioritize upon the child's arrival?
Observing for signs of respiratory distress.
Monitoring vital signs for indications of shock.
Obtaining a detailed history of the burn incident.
Evaluating the extent and depth of the burns.
The Correct Answer is A
Choice A rationale
Observing for signs of respiratory distress is the priority assessment for a child with burns to the face and neck. Burns in this area can lead to airway edema and compromise, which can rapidly become life-threatening. Assessing for stridor, hoarseness, difficulty breathing, and changes in respiratory rate and effort is crucial for immediate intervention.
Choice B rationale
Monitoring vital signs for indications of shock is important in burn patients due to fluid shifts and potential hypovolemia. However, airway patency takes precedence, as inadequate oxygenation will quickly lead to irreversible damage. Vital signs should be monitored continuously after ensuring the airway is secure.
Choice C rationale
Obtaining a detailed history of the burn incident is necessary for understanding the mechanism of injury and potential associated trauma. However, the immediate priority is to assess and manage any threats to the child's airway, breathing, and circulation. History taking can occur once the child is stable.
Choice D rationale
Evaluating the extent and depth of the burns is crucial for determining the severity of the injury and guiding fluid resuscitation and wound care. However, ensuring a patent airway and adequate breathing is the immediate priority upon the child's arrival in the emergency department.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Pain is a common symptom in superficial and partial-thickness burns where nerve endings are still intact. While pain indicates tissue damage, the absence of pain in a burn area can signify deeper and more severe injury where nerve endings have been destroyed.
Choice B rationale
No pain with pale, leathery skin is a characteristic finding of a full-thickness (third-degree) burn. The destruction of nerve endings eliminates pain sensation, and the skin appears dry, leathery, and may be white, charred, or translucent due to damage to all skin layers and underlying tissue.
Choice C rationale
Mild erythema, or redness of the skin, is characteristic of a superficial (first-degree) burn, such as a sunburn. These burns involve only the epidermis and are typically painful and without blisters.
Choice D rationale
Blister formation is a hallmark of partial-thickness (second-degree) burns, which involve the epidermis and part of the dermis. These burns are typically painful and moist.
Correct Answer is C
Explanation
Choice A rationale
Corn is naturally gluten-free and is generally safe for individuals with celiac disease to consume. Celiac disease is an autoimmune disorder triggered by gluten, a protein found in wheat, barley, and rye.
Choice B rationale
Rice, in all its forms (white, brown, wild), is naturally gluten-free and is a staple grain in the diet of individuals with celiac disease. It does not contain the gliadin protein that triggers the autoimmune response in celiac disease.
Choice C rationale
Wheat contains gluten, specifically the gliadin fraction, which triggers the damaging autoimmune response in the small intestine of individuals with celiac disease. Therefore, all products containing wheat, including bread, pasta, and many processed foods, must be strictly avoided.
Choice D rationale
Oats are naturally gluten-free; however, they are often processed in facilities that also handle wheat, barley, or rye, leading to cross-contamination. While certified gluten-free oats are available, regular oats may not be safe for individuals with celiac disease due to this risk of contamination.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.