A nurse is assessing a 12-year-old client who presents with a partial thickness burn. Which of the following does the nurse suspect is the cause of the client's condition?
Contact with hot liquid.
An electrical source.
Contact with a flame.
A mild sunburn.
The Correct Answer is A
Choice A reason: Partial thickness burns, affecting the epidermis and dermis, are commonly caused by hot liquids, like scalds, in children. These burns cause blisters and pain due to thermal damage penetrating deeper skin layers, consistent with the described injury, making this the likely cause.
Choice B reason: Electrical burns often cause deeper, full-thickness burns due to high-energy current penetrating tissues, causing necrosis beyond the dermis. Partial thickness burns are less typical, as electrical injuries tend to damage underlying muscles and nerves, making this an unlikely cause.
Choice C reason: Flame burns typically cause full-thickness burns, destroying the epidermis and dermis due to intense heat. Partial thickness burns are less common, as flames often result in deeper tissue damage, making this a less likely cause compared to hot liquid scalds.
Choice D reason: Mild sunburns cause superficial burns, affecting only the epidermis with redness and minimal pain. Partial thickness burns involve deeper dermal layers with blistering, which sunburns rarely cause unless severe, making this an unlikely cause for the described burn depth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The Glasgow Coma Scale assesses cognitive status by evaluating eye-opening, verbal, and motor responses. It quantifies consciousness level after a head injury, detecting neurological impairment due to trauma. This non-invasive tool provides immediate data on brain function, guiding further diagnostic and treatment decisions.
Choice B reason: A CT scan identifies structural brain injuries, like hematomas, but does not directly assess cognitive function. It visualizes anatomical damage rather than real-time neurological status, making it secondary to tools like the Glasgow Coma Scale for immediate cognitive assessment post-injury.
Choice C reason: Blood work can detect metabolic or infectious causes of altered cognition but does not directly evaluate cognitive status. It may reveal secondary issues like hypoglycemia but lacks specificity for assessing brain function after a head injury, making it less relevant for this purpose.
Choice D reason: Monitoring intracranial pressure is critical in severe head injuries but requires invasive devices and does not directly assess cognitive status. It measures pressure dynamics, not consciousness or cognitive function, making it inappropriate for initial cognitive evaluation compared to the Glasgow Coma Scale.
Correct Answer is D
Explanation
Choice A reason: Oliguria, reduced urine output, is associated with renal or dehydration issues, not directly with central nervous system infections. While meningitis may cause systemic effects, oliguria is not a hallmark sign, as neurological symptoms like fontanel changes are more specific indicators.
Choice B reason: A negative Brudzinski sign indicates no neck stiffness, which is inconsistent with central nervous system infections like meningitis, where meningeal irritation causes a positive sign. This finding suggests the absence of infection, making it an incorrect manifestation for this condition.
Choice C reason: Jaundice, caused by liver dysfunction or hemolysis, is not typically associated with central nervous system infections. Meningitis primarily affects the meninges, causing neurological symptoms, not bilirubin elevation, making jaundice an unrelated finding in this context.
Choice D reason: A bulging fontanel in an 11-month-old indicates increased intracranial pressure from a central nervous system infection like meningitis. Meningeal inflammation causes cerebrospinal fluid buildup, pressing on the open fontanel, a key diagnostic sign in infants with neurological infections.
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