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 C
Explanation
A. A dry, hacking cough is a classic sign of left-sided heart failure, where blood backs up into the pulmonary circulation, causing pulmonary congestion and irritation of airway receptors. In isolated RV failure, pulmonary symptoms are usually minimal unless left-sided failure is also present (biventricular failure).
B. Crackles (rales) result from pulmonary edema, which is a hallmark of left-sided heart failure. In RV failure, the lungs are generally not congested, so crackles are not expected unless there is concomitant left ventricular dysfunction.
C. RV failure leads to increased venous pressure in the systemic circulation, causing congestion in the liver (hepatomegaly). This can manifest as right upper quadrant fullness or tenderness, impaired liver function, and in chronic cases, nutmeg liver from long-standing congestion. Other systemic signs include jugular vein distension, peripheral edema (especially in the lower extremities), ascites, and weight gain due to fluid retention.
D. While dizziness can occur in any form of heart failure due to decreased cardiac output, it is nonspecific and is not considered a primary or hallmark sign of right-sided heart failure.
Correct Answer is D
Explanation
Rationale:
A. The total body surface area (TBSA) of an adult is divided using the rule of nines, which assigns approximate percentages to body regions for rapid burn assessment. The head does not account for 12% of TBSA in adults.
B. This percentage is more appropriate for specific smaller areas, such as a single limb segment in children, but not the entire adult head.
C. The adult head is not that large proportionally; this value overestimates the TBSA contribution of the head.
D. According to the rule of nines, the adult head, including the face and scalp, accounts for 9% of total body surface area. This standardized method allows for quick estimation of burn size, guiding fluid resuscitation and treatment planning. Each arm accounts for 9%, each leg 18%, the anterior trunk 18%, posterior trunk 18%, and the perineum 1%.
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