A 7-year-old child accidentally touches a hot stove, resulting in redness on his palm without blisters.
What type of burn is this?
First-degree burn.
Second-degree burn.
Third-degree burn.
Full-thickness burn.
The Correct Answer is A
Choice A rationale
A first-degree burn involves only the epidermis, the outermost layer of the skin. It is characterized by redness (erythema), pain, and dryness, without the formation of blisters. The superficial damage affects the outer layer of epithelial cells, causing vasodilation and inflammation, leading to the observed redness and discomfort.
Choice B rationale
A second-degree burn involves the epidermis and a portion of the dermis, the layer beneath the epidermis. These burns are characterized by blisters, significant pain, redness, and swelling. The damage extends deeper into the skin, affecting nerve endings and blood vessels, leading to fluid leakage and blister formation.
Choice C rationale
A third-degree burn involves the destruction of the epidermis and the entire dermis, potentially extending into the subcutaneous tissue. These burns appear white or charred, are often painless initially due to nerve damage, and lack blisters. The full thickness destruction of skin layers impairs sensation and requires significant medical intervention, often including skin grafting.
Choice D rationale
Full-thickness burn is another term for a third-degree burn, indicating that all layers of the skin have been destroyed. This type of burn extends through the epidermis and dermis and may involve underlying subcutaneous tissue, muscle, or bone. The appearance is typically dry, leathery, and may be white, charred, or waxy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Initiating feeding too soon after pyloromyotomy, a surgical repair of the pyloric sphincter, can lead to vomiting and aspiration in the immediate postoperative period. The gastrointestinal system needs time to recover from anesthesia and the surgical manipulation to the pylorus, which controls the passage of food from the stomach to the small intestine. Introducing fluids prematurely can overwhelm the healing surgical site.
Choice B rationale
Encouraging parental bonding and cuddling is crucial for the psychosocial well-being of the infant and parents. However, in the immediate postoperative phase, physiological stability takes precedence. While emotional support is important, addressing potential complications and assessing the infant's physical status are the priority actions.
Choice C rationale
Documenting the surgical site appearance is an important nursing responsibility to monitor for signs of infection, bleeding, or dehiscence. However, assessing the infant's immediate postoperative condition, particularly pain, which can indicate complications or discomfort, is a more immediate concern. Pain management directly impacts the infant's physiological stability.
Choice D rationale
Identifying signs of pain using an appropriate pain scale is the priority intervention in a post-operative infant. Pain can lead to physiological instability, such as increased heart rate, blood pressure, and respiratory distress. Early identification and management of pain ensure the infant's comfort and facilitate recovery. Utilizing a validated pain scale for infants allows for objective assessment of pain levels and guides appropriate interventions.
Correct Answer is C
Explanation
Choice A rationale
Avoiding fruit juice is a helpful recommendation because fruit juices are often high in simple sugars, which can draw water into the bowel and potentially worsen diarrhea. This statement indicates a good understanding of dietary management for diarrhea.
Choice B rationale
Offering small amounts of oral rehydration solution frequently is a crucial aspect of managing acute diarrhea in toddlers to prevent dehydration by replacing lost fluids and electrolytes. This demonstrates appropriate knowledge of fluid management.
Choice C rationale
Giving over-the-counter antidiarrheal medicine to stop the stools is generally not recommended for toddlers with acute diarrhea without specific guidance from a healthcare provider. These medications can sometimes mask underlying issues or have adverse effects in young children. This statement indicates a need for further explanation regarding safe medication use.
Choice D rationale
Continuing to offer the child their usual foods as tolerated is generally advised to maintain nutritional intake during diarrhea. Bland foods like toast, rice, bananas, and applesauce are often well-tolerated. This shows an understanding of appropriate dietary progression.
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