A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?
Skin is red, blanches, and weeps
Skin has a leathery and dry
Skin is waxy in appearance
Skin is intact, dry, and red in color
The Correct Answer is A
A. Skin is red, blanches, and weeps: This is consistent with deep partial-thickness burns. These burns damage deeper layers but still allow capillary refill and exudate.
B. Skin has a leathery and dry: This is characteristic of full-thickness (third-degree) burns.
C. Skin is waxy in appearance: A waxy appearance suggests full-thickness burns.
D. Skin is intact, dry, and red in color: This indicates superficial (first-degree) burns like sunburn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Blistering of area: Blisters are characteristic of superficial partial-thickness burns, involving the epidermis and part of the dermis.
B. Dry crusting surface: This is more typical of deeper burns; partial-thickness burns are moist.
C. Intact skin surface: The skin is not intact; it is damaged and blistered.
D. Blanching of wound area: Indicates intact capillary refill and superficial depth.
E. Pain at wound site: Nerve endings are exposed, making these burns very painful.
Correct Answer is B
Explanation
A. Hamburger on a bun and a banana: Bananas are high in potassium, which must be restricted in CKD. Processed hamburger meat may also be high in sodium and phosphorus.
B. Spaghetti and meat sauce with breadsticks: Pasta and meat sauce are generally low in potassium and phosphorus if made without salt substitutes. Breadsticks are low in potassium.
C. Carrots and spinach: Spinach is high in potassium and phosphorus. Cooked carrots are borderline and must be portion-controlled.
D. Cold cuts with bun and fresh pears: Cold cuts are typically high in sodium and phosphorus. Pears are generally acceptable, but the entire meal is unsuitable due to the cold cuts.
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