A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

Choice A reason: Epithelialization at the site of a major full-thickness burn would not be expected 12 hours post-injury. Epithelialization is a later stage of wound healing where new skin cells form and cover the wound. In full-thickness burns, this process is significantly delayed and typically requires skin grafting for wound closure.

Choice B reason: Severe pain is not typically associated with full-thickness burns due to the destruction of nerve endings in the skin. However, there may be severe pain in the surrounding areas that have sustained less severe burns.

Choice C reason: Edema is a common and expected finding at the site of a major full-thickness burn 12 hours post-injury. The inflammatory response to the burn injury leads to increased vascular permeability and fluid shift from the intravascular to the interstitial space, resulting in edema.

Choice D reason: Blistering is characteristic of partial-thickness burns (second-degree burns) but not full-thickness burns (third-degree burns). In full-thickness burns, the skin is destroyed to the point where blisters do not form.

Choice A reason : Pressing down on the orbital area of the eye is not a recommended method for eliciting a response from a painful stimulus in an unresponsive patient due to the potential for injury to the eye.

Choice B reason : Pressing down on the trapezius muscle is an acceptable method for eliciting a response from a painful stimulus in an unresponsive patient. This technique is less invasive and can be performed safely to assess the patient's level of consciousness or response to pain without causing harm⁸.

Choice C reason : Using a 25-gauge needle is not an appropriate method for eliciting a response from a painful stimulus in an unresponsive patient. This could cause unnecessary harm and is not a standard practice in clinical settings.

Choice D reason : Eliciting a reflex with a reflex hammer is a method used to assess reflexes, not to elicit a response from a painful stimulus in an unresponsive patient. This tool is used to test neurological function and reflex integrity, not to assess pain response.