How should the nurse classify a burn injury that involves the epidermis and part of the dermis, with red skin and pain, but no blisters present after exposure to hot water?
Deep partial-thickness burn
Electrical burn
Superficial partial-thickness burn
Full-thickness burn
The Correct Answer is C
Rationale:
A. Deep partial-thickness burn involves the entire epidermis and most of the dermis, including deeper dermal structures such as hair follicles and sweat glands. These burns are typically red or white, moist or mottled, often very painful, and usually form blisters. Healing is slower and may require surgical intervention. Since the client’s burn shows no blisters and only involves part of the dermis superficially, this classification does not fit.
B. Electrical burn is caused by passage of electrical current through the body. It often produces internal tissue damage that may be more severe than the skin findings suggest. There is no indication in this scenario that electricity caused the injury, so this classification is inappropriate.
C. Superficial partial-thickness burn is correct. These burns involve the epidermis and the upper portion of the dermis. The skin appears red and painful, and blisters may or may not be present immediately after the injury. Superficial partial-thickness burns usually heal within 10–21 days without significant scarring. In this case, the burn resulted from hot water exposure, is red, painful, and shows no blisters, which aligns with a superficial partial-thickness burn.
D. Full-thickness burn involves all layers of the skin, including the epidermis, dermis, and sometimes underlying tissues such as fat, muscle, or bone. The affected area may appear white, brown, black, or leathery, and is often painless due to nerve destruction. Since the client’s burn is red, painful, and only partially involves the dermis, it does not qualify as full-thickness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Regulate red blood cell production in the bone marrow is incorrect. Red blood cell production, or erythropoiesis, is controlled by erythropoietin, a hormone secreted primarily by the kidneys in response to low oxygen levels. Goblet cells have no role in this process. They are epithelial cells specialized for mucus secretion, not involved in hematopoiesis or the regulation of blood cell production.
B. Secrete mucus to trap dust and particles in the nasal cavity is correct. Goblet cells are unicellular glands located within the epithelial lining of the respiratory and gastrointestinal tracts. Their main function is to produce mucus, a sticky secretion that traps dust, microbes, and other particles, preventing them from reaching delicate tissues. In the respiratory system, mucus works together with cilia in a process called the mucociliary escalator, which moves trapped particles upward and out of the airways to maintain pulmonary health. Goblet cells also help moisturize mucosal surfaces, protecting them from drying and injury.
C. Produce antibodies to fight infections is incorrect. Antibodies are proteins produced by B lymphocytes and plasma cells as part of the adaptive immune system. Goblet cells do not have the machinery to produce immunoglobulins or participate in specific immune responses. While mucus does provide some nonspecific immune protection by trapping pathogens, it is not involved in antibody production.
D. Generate platelets for blood clotting is incorrect. Platelets are fragments of cytoplasm derived from megakaryocytes in the bone marrow and play a critical role in hemostasis. Goblet cells are unrelated to the clotting system and do not contribute to platelet formation or blood coagulation.
Correct Answer is B
Explanation
Rationale:
A. Recurrent urinary frequency may occur as a symptom of urinary tract obstruction or irritation, but it is a relatively minor and common manifestation. While uncomfortable for the client, urinary frequency itself is not the most serious or life-threatening complication of hydronephrosis.
B. Renal failure is the primary concern in a client with hydronephrosis caused by an untreated kidney stone. Hydronephrosis occurs when urine flow is obstructed, leading to increased pressure within the renal pelvis and calyces. This pressure compresses renal tissue, impairs blood flow, and damages nephrons. If the obstruction persists, it can result in progressive kidney damage and potentially irreversible renal failure. The longer the obstruction remains untreated, the higher the risk of permanent loss of renal function, making renal failure the most serious and concerning complication.
C. Diabetic nephropathy is a form of chronic kidney disease caused by long-term diabetes mellitus. It is unrelated to hydronephrosis from urinary obstruction. While clients with diabetes may have an increased risk of kidney disease, diabetic nephropathy is not a direct complication of untreated kidney stones.
D. Orthostatic hypotension is a drop in blood pressure upon standing, often caused by dehydration, autonomic dysfunction, or certain medications. It is not a direct complication of hydronephrosis and is less clinically urgent than the risk of renal failure in this context.
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