A nurse is assisting with the care of an adolescent who has a partial-thickness burn. When observing the site of the burn, which of the following clinical manifestations should the nurse expect?
Brown in color.
Leathery appearance.
Visible ligaments.
Blister formation.
The Correct Answer is D
Choice A reason:
Brown in color. The rationale for this choice is that a partial-thickness burn involves damage to the epidermis and the dermis but not the full thickness of the skin. It typically presents with redness, swelling, and blisters. While the burned area may have some discoloration, it is more likely to be red or pink rather than brown. Brown coloration would suggest a deeper burn involving the full thickness of the skin and potentially underlying structures.
Choice B reason:
Leathery appearance. This choice is not expected in a partial-thickness burn. A leathery appearance is characteristic of a full-thickness (third-degree) burn, which involves the destruction of the epidermis, dermis, and potentially deeper tissues. In a partial-thickness burn, the skin may appear red, swollen, and blistered, but it should not have a leathery texture.
Choice C reason:
Visible ligaments. This choice is not indicative of a partial-thickness burn either. Partial- thickness burns primarily affect the epidermis and dermis, but they do not extend deep enough to expose ligaments or other structures below the skin. Visible ligaments would suggest a full-thickness burn or an injury that extends beyond the skin layers.
Choice D reason:
Blister formation. This is the correct choice. Blister formation is a common clinical manifestation of a partial-thickness burn. The injury causes fluid accumulation between the layers of the skin (epidermis and dermis), leading to the formation of blisters. The blisters may be filled with clear fluid and are usually painful and sensitive to touch.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Experiences separation anxiety - This is a common behavior seen in toddlers during hospitalization. Being away from their parents or caregivers and being in an unfamiliar environment can lead to feelings of anxiety and distress. Separation anxiety is a natural response for young children who rely on their primary caregivers for comfort and security.
Choice B reason:
Fears a loss of control - Toddlers may feel overwhelmed and fearful when they find themselves in a hospital setting. The loss of control over their daily routines and environment can be frightening for them. They may be unable to understand the reasons behind medical procedures or interventions, further increasing their anxiety.
Choice C reason:
Feels hospitalization is punishment - While some children might have difficulty understanding the reasons for hospitalization, it is less common for them to perceive it as punishment.
Children at this age often lack the cognitive capacity to associate their illness with punishment.
Choice D reason:
Develops body image disturbance - Body image disturbance is not a typical behavior observed in toddlers during hospitalization. This issue is more common in older children or adolescents who may experience changes in their appearance due to medical conditions or treatments.
Correct Answer is B
Explanation
Choice A reason: Following the rupture of membranes, delivery is imminent and administration of glucocorticoids may not take effect to benefit the baby.
Choice B reason:
Monitoring the client's temperature (Choice B) is important as the client is at risk of chorioamnionitis which may increase the risk of severe early neonatal sepsis. Changes in temperature as they may warrant anibiotic therapy and immediate delivery.
Choice C reason:
Giving calcium gluconate (Choice C) is not indicated in this situation. Calcium gluconate is typically administered in cases of magnesium sulfate toxicity or to treat hypocalcemia, neither of which is mentioned in the scenario. Therefore, it is not the appropriate action for the nurse to take at this time.
Choice D reason:
Preparing the client for an amniocentesis (Choice D) is not the correct action in this situation. An amniocentesis is a procedure in which a small amount of amniotic fluid is withdrawn for various diagnostic reasons, such as genetic testing or assessing fetal lung maturity. However, in this scenario, the priority is to administer glucocorticoids to promote fetal lung maturity, and an amniocentesis does not address this immediate concern.
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