A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?

The burned area is yellow in color with severe edema.

The burned area is black in color and pain is absent.

The burned area is pink in color with blisters present.

The burned area is red in color with soft eschar present.

Answer and Explanation

The Correct Answer is D

Choice A Reason: The burned area is yellow in color with severe edema is not a finding of a deep partial-thickness burn, but a superficial partial-thickness burn. A superficial partial-thickness burn involves the epidermis and the upper layer of the dermis, causing pain, redness, swelling, and blistering.

Choice B Reason: The burned area is black in color and pain is absent is not a finding of a deep partial-thickness burn, but a full-thickness burn. A full-thickness burn involves the epidermis, dermis, and underlying tissues, causing necrosis, charred skin, and loss of sensation.

Choice C Reason: This description aligns with a superficial partial-thickness (first-degree or mild second-degree) burn rather than a deep partial-thickness burn. Superficial partial-thickness burns involve the epidermis and the upper portion of the dermis. These burns appear pink or red, often accompanied by moisture and blister formation due to fluid leakage from damaged capillaries. They are painful because nerve endings remain intact. Healing occurs within 10 to 21 days without significant scarring.

Choice D Reason: Deep partial-thickness burns extend deeper into the dermis, damaging a larger portion of skin structures, including sweat glands and hair follicles. These burns typically appear red or white and may have a soft eschar (dead tissue), which differentiates them from more superficial burns that do not develop eschar. Unlike full-thickness burns, nerve endings remain partially intact, so the patient may still experience some pain. These burns take more than 21 days to heal and often require skin grafting to prevent complications such as contractures or hypertrophic scarring.

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Correct Answer is C

Explanation

Choice A Reason: This choice is incorrect. Inability to read is not a finding that the nurse should expect in a client who has meningitis, but rather a possible finding in a client who has a stroke or a brain tumor. Meningitis does not affect the language or cognitive functions, but rather the meninges or the membranes that cover the brain and spinal cord.

Choice B Reason: This choice is incorrect. Bruising around the eyes is not a finding that the nurse should expect in a client who has meningitis, but rather a possible finding in a client who has a basilar skull fracture or a head trauma. Meningitis does not cause bleeding or bruising, but rather inflammation and infection of the meninges.

Choice C Reason: This is the correct choice. A throbbing headache is a finding that the nurse should expect in a client who has meningitis, as it is one of the most common and characteristic symptoms. A throbbing headache is caused by increased intracranial pressure and irritation of the meninges due to inflammation and infection.

Choice D Reason: This choice is incorrect. A heart rate of 50 is not a finding that the nurse should expect in a client who has meningitis, but rather a possible finding in a client who has bradycardia or a slow heart rate. Meningitis does not affect the heart rate, but rather the temperature and blood pressure. The nurse should expect to see fever and hypotension in a client who has meningitis.

A. 36 percent B. 54 percent C. 27 percent D. 18 percent E. 9 percent

Correct Answer is A

Explanation

Choice A Reason: This is the correct choice. Using the rule of nines, each arm accounts for 9 percent of TBSA, each leg accounts for 18 percent of TBSA, and front and back are equally divided. Therefore, burns on both sides of both arms and legs equal to (9 + 9) x 2 + (18 + 18) x 2 = 36 percent of TBSA.

Choice B Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 54 percent. To get 54 percent of TBSA, one would have to add burns on both sides of head and neck (9 percent), chest (9 percent), and abdomen (9 percent).

Choice C Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 27 percent. To get 27 percent of TBSA, one would have to subtract burns on both sides of one leg (18 percent).

Choice D Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 18 percent. To get 18 percent of TBSA, one would have to divide burns on both sides of both arms and legs by two.

Choice E Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 9 percent. To get 9 percent of TBSA, one would have to divide burns on both sides of both arms and legs by four.

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A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

Correct Answer is A

Explanation

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