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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Soft pasty stool is normal for a transverse colostomy, as the stool has not reached the sigmoid colon where most of the water is absorbed.
Choice B Reason: This is the correct answer because purple discoloration of the stoma indicates ischemia or necrosis, which can lead to infection, perforation, or sepsis. It requires urgent intervention.
Choice C Reason: Stoma is beefy red is a normal finding for a healthy stoma, as it indicates adequate blood supply and healing.
Choice D Reason: There is skin excoriation around the stoma is a common complication of a colostomy, as the stool can irritate the skin. It can be managed with proper skin care and appliance fitting.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because inability to recognize any words may indicate a problem with the auditory cortex, which is the part of the brain that processes sound, not the inner ear. The inner ear consists of the cochlea, which converts sound waves into nerve impulses, and the vestibular system, which helps with balance and orientation.
Choice B Reason: This is correct because loss of balance is a common symptom of an inner ear infection. An inner ear infection can cause inflammation and fluid buildup in the vestibular system, which can disrupt the sense of equilibrium and cause vertigo, dizziness, or nausea.
Choice C Reason: This is incorrect because twitching of the cheek may indicate a problem with the facial nerve, which controls the muscles of facial expression, not the inner ear. The facial nerve runs close to the inner ear, but it is not part of it.
Choice D Reason: This is incorrect because lack of air sound may indicate a problem with the outer or middle ear, which transmit sound waves to the inner ear, not the inner ear itself. The outer ear consists of the pinna and the ear canal, and the middle ear consists of the eardrum and the ossicles.
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