The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?
Deep partial-thickness.
Full-thickness.
Superficial partial-thickness.
Deep full-thickness.
The Correct Answer is B
Choice A reason: Deep partial-thickness burns are characterized by blisters and significant pain.
Choice B reason:
The correct answer is b) because full-thickness burns involve all layers of the skin and can extend into underlying tissues. They often appear brown or yellow and are usually painless due to nerve damage.
Choice C reason: Superficial partial-thickness burns affect the epidermis and part of the dermis, causing pain and redness.
Choice D reason: Deep full-thickness burns are also a possible answer, but full-thickness better describes the extent and characteristics given.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Placing an indwelling urinary catheter is not immediately relevant to the client's symptoms.
Choice B reason: Giving an analgesic for a fever does not address the underlying issue of bowel obstruction.
Choice C reason: Sending the client to x-ray can help diagnose the issue but is not the first action to relieve symptoms.
Choice D reason:
The correct answer is d) because inserting a nasogastric tube and attaching it to low intermittent suction helps decompress the stomach and relieve symptoms of bowel obstruction.
Correct Answer is C
Explanation
Choice A reason: Assessing the extremity reflexes is important for evaluating neurological function but is not the immediate priority.
Choice B reason: Logrolling to change positions is a technique used to maintain spinal alignment, but it is not the first intervention to ensure immediate safety.
Choice C reason:
The correct answer is c) because immobilizing the head in anatomical alignment is crucial to prevent further injury to the spinal cord. Proper immobilization helps stabilize the cervical spine and protects the spinal cord from additional damage.
Choice D reason: Obtaining hourly neurological assessments is important for monitoring the client's condition but comes after ensuring the cervical spine is properly immobilized.
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