The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?
Superficial partial-thickness.
Full-thickness.
Deep partial-thickness.
Deep full-thickness.
The Correct Answer is B
Choice A rationale
A superficial partial-thickness burn involves the destruction of the epidermis and possibly a portion of the dermis. The description provided does not match this type of burn.
Choice B rationale
A full-thickness burn involves total destruction of the epidermis and dermis, and in some cases, the underlying tissue, muscle, and bone. The description of the burn as severely swollen, with a wound bed that appears brown and yellow, and the patient reporting no pain, is consistent with a full-thickness burn.
Choice C rationale
A deep partial-thickness burn involves the destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis. The description provided does not match this type of burn.
Choice D rationale
Deep full-thickness burns are a more severe form of full-thickness burns that extend beyond the dermis into deeper tissues. The description provided does not match this type of burn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Encouraging the client to continue their walking routine is a supportive and positive response. This acknowledges the client’s desire to stay active and engage in activities they enjoy despite their osteoarthritis. It promotes a sense of empowerment and independence, which can be important for overall well-being.
Choice B rationale
Advising less weight-bearing to prevent joint destruction may seem logical, but it is not the best advice. Regular exercise, including walking, can actually help manage osteoarthritis by strengthening the muscles around the joints, improving flexibility, and reducing pain.
Choice C rationale
Recommending walking indoors for improved stability and safety might be helpful in some cases, but it is not necessarily the best response. The client has expressed a desire to continue walking in the park with friends, which also has social and mental health benefits.
Choice D rationale
Suggesting a calcium supplement along with continued walking is not the best advice. While calcium is important for bone health, osteoarthritis is not caused by a lack of calcium. It’s a degenerative joint disease that involves the breakdown of cartilage in the joints.
Correct Answer is B
Explanation
Choice A rationale
While the renin-angiotensin response can be affected in cirrhosis, it is not the primary mechanism contributing to edema and ascites. In cirrhosis, there can be a decrease in renal blood flow which can lead to activation of the renin-angiotensin system, but this is not the main cause of fluid accumulation.
Choice B rationale
Hypoalbuminemia, or low levels of albumin in the blood, is a common occurrence in cirrhosis. Albumin is a protein that helps maintain oncotic pressure, which keeps fluid in the blood vessels. When albumin levels are low, fluid can leak out of the blood vessels and accumulate in the abdomen (ascites) and in the tissues, causing edema.
Choice C rationale
Hyperaldosteronism can occur in cirrhosis and can contribute to fluid retention. However, it is not the primary mechanism leading to edema and ascites. Aldosterone promotes sodium and water reabsorption in the kidneys, which can contribute to fluid retention, but this is usually a secondary response to other changes in the body.
Choice D rationale
Decreased portacaval pressure with greater collateral circulation is not the primary mechanism contributing to edema and ascites in cirrhosis. While portal hypertension is a common complication of cirrhosis, it is not directly responsible for the development of edema and ascites.
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