A nurse is caring for a preschooler with a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.).
Intact epidermis.
Dry surface.
Sensitive to touch.
Wound blanches with pressure.
Blisters.
Correct Answer : C,D,E
The correct answers are C, D, and E.
Choice A rationale: Intact epidermis would not be expected with a partial-thickness burn as the burn extends into the dermis.
Choice B rationale: A dry surface is not characteristic of partial-thickness burns, which typically have a moist surface.
Choice C rationale: Partial-thickness burns are sensitive to touch due to the damage to nerve endings in the dermis.
Choice D rationale: Wound blanches with pressure because the blood vessels are damaged, allowing blanching on pressure.
Choice E rationale: Blisters are a common feature of partial-thickness burns, as the damage to the dermis causes fluid to accumulate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Contact the provider to clarify the dosage and frequency of medication administration.
The nurse should always verify the dosage and frequency of medication administration with the provider before administering any medication to ensure the safety and well-being of the infant.
Choice A is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
Choice B is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
Choice C is not an answer because waiting and monitoring the infant’s symptoms does not address the need to verify the dosage and frequency of medication administration with the provider.
Correct Answer is C
Explanation
A bulging fontanel is a manifestation associated with a CNS infection in an 11- month-old infant.
A bulging fontanel can be a sign of increased intracranial pressure, which can
occur with meningitis or encephalitis, both of which are types of CNS infections.
Choice A is incorrect because oliguria, or decreased urine output, is not typically associated with a CNS infection.
Choice B is incorrect because jaundice, or yellowing of the skin and eyes, is not typically associated with a CNS infection.
Choice D is incorrect because a negative Brudzinski sign would indicate that there is no neck stiffness, which would be an unlikely finding in a CNS infection.
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