A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.)
Blisters
Wound blanches with pressure
Dry face
Intact epidermis
Sensitive to touch
Correct Answer : A,B,E
Choice A rationale: partial-thickness burns are usually characterized by the formation of blisters as a result of increased capillary permeability resulting in edema formation separating the epidermis from the dermis.
Choice B rationale: wound blanching with pressure is expected in partial-thickness burns due to compromised blood circulation.
Choice C rationale: This is not a typical finding in a partial-thickness burn.
Choice D rationale: this is incorrect since partial-thickness burns involve damage to the epidermis.
Choice E rationale: nerve endings are damaged in partial-thickness burns thus making the area sensitive to touch.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Hemoglobin level reflects the oxygen-carrying capacity of the blood but is not a direct indicator of nutritional status.
Choice B rationale: International Normalized Ratio (INR) is a measure of blood clotting, and a normal value does not directly impact wound healing.
Choice C rationale: Serum albumin is a marker of nutritional status, and a low level (hypoalbuminemia) can adversely affect wound healing. Adequate protein intake is essential for collagen synthesis and overall tissue repair.
Choice D rationale: White blood cell count is an indicator of immune response and infection but does not directly affect wound healing in the absence of infection.
Correct Answer is A
Explanation
Choice A rationale: Pain management is a crucial aspect of care for a client with herpes zoster (shingles). Administering analgesics can help alleviate pain and improve the client's overall comfort.
Choice B rationale: Herpes zoster is not spread through respiratory droplets, so restricting visitors based on their vaccination status is not necessary.
Choice C rationale: Protective isolation is not required for herpes zoster, as it is not highly contagious.
Choice D rationale: There is no need to avoid alcohol-based hand rubs in the care of a client with herpes zoster.
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