A patient is brought to the emergency department after a house fire. the patient has extensive trunk and lower extremity burns and is diagnosed with a full thickness burn. What assessment findings does the nurse expect?
Bright-red, moist lesions
Blackened, painful lesions
Snowy white, painless lesions
Blistered, pinkish-white, painful lesions
The Correct Answer is C
A. Bright-red, moist lesions:
This describes superficial partial-thickness burns, not full-thickness burns.
B. Blackened, painful lesions:
Full-thickness burns may appear black (eschar), but they are typically painless due to nerve destruction.
C. Snowy white, painless lesions:
Full-thickness burns can be white, leathery, or charred and are often painless due to complete nerve damage.
D. Blistered, pinkish-white, painful lesions:
These are characteristic of deep partial-thickness burns, which retain some nerve sensation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Perform hourly neurological assessments on the client:
Important, but not the first action. Neurological symptoms may improve with oxygenation.
B. Administer oxygen to the client at 100%:
CO binds to hemoglobin with a higher affinity than oxygen. 100% oxygen displaces CO and is the priority intervention to reduce hypoxia.
C. Institute seizure precautions for the client:
Useful if the client becomes neurologically compromised, but not the priority over oxygenation.
D. Provide ondansetron IV to the client for nausea:
Nausea can occur in CO poisoning, but treating hypoxia is the priority.
Correct Answer is []
Explanation
Most Likely Condition:
Herpes zoster (Shingles): The client presents with a painful, burning, unilateral rash in a dermatomal distribution with grouped vesicles on an erythematous base — classic for herpes zoster (shingles). The shoulder x-ray is normal, ruling out musculoskeletal causes.
Actions to Take:
Anticipate administering an antiviral medication: Antiviral medications like acyclovir, valacyclovir, or famciclovir reduce the severity and duration of shingles if started early.
Request a prescription analgesic medication: Shingles is often extremely painful. Ibuprofen was ineffective, so stronger analgesics are likely needed.
Parameters to Monitor:
Pain: Pain monitoring assesses the effectiveness of analgesic and antiviral treatment.
Post-herpetic neuralgia (nerves): Monitoring for lingering nerve pain is crucial, as shingles can lead to long-term nerve damage.
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