A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.
Muscle layers
Epidermal layers
Dermal layers
Subcutaneous layers
Bone and ligaments
Correct Answer : A,B,C,D
A. Muscle layers: Full-thickness burns may extend into muscle, especially with chemical burns.
B. Epidermal layers: The outermost layer is completely destroyed in full-thickness burns.
C. Dermal layers: Full-thickness burns extend through both the epidermis and dermis.
D. Subcutaneous layers: These burns also involve the subcutaneous fat and connective tissue.
E. Bone and ligaments: Involvement of bone and ligaments would indicate a 4th-degree burn, not 3rd-degree.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Assessing the client's support system: Important in overall care, but not a priority in the acute phase.
B. Assessing and removing any rings or jewelry from affected limb: Jewelry can cause constriction due to swelling; removing it prevents further vascular compromise.
C. Assessing the client's circulation distal to the burn site: Circumferential burns can compromise perfusion due to edema or eschar formation. Checking pulses, cap refill, and sensation is essential.
D. Assessing the client's urine output: Important in systemic burns, but not directly related to a localized forearm burn.
E. Assessing the client's respiratory function: Critical in burns involving the face or inhalation injury, but not the forearm.
Correct Answer is B
Explanation
A. Acute hemolysis: While it is a complication of dialysis, it typically presents with back pain, dark red urine, and hypotension.
B. Disequilibrium syndrome: Caused by rapid removal of urea during dialysis, leading to cerebral edema. Early signs include nausea, headache, restlessness, and confusion.
C. Septic shock: Presents with hypotension, tachycardia, and signs of infection. Not the most likely with nausea and headache alone.
D. Air embolism: Presents with sudden chest pain, dyspnea, and hypotension; not typically with headache and restlessness alone.
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