When assessing a client who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale and hard. The client states that the burn is not painful. What term would the nurse use to document the burn depth?

Superficial partial-thickness skin destruction

First-degree skin destruction

Full-thickness skin destruction

Deep partial-thickness skin destruction

Answer and Explanation

The Correct Answer is C

A. Superficial partial-thickness skin destruction: Superficial partial-thickness burns involve the epidermis and part of the dermis, causing redness, pain, and blistering. The skin is usually moist and blanches with pressure.

B. First-degree skin destruction: First-degree burns involve only the epidermis and are typically red and painful, with no blistering. The description of dry, pale, and hard skin suggests a more severe burn than a first-degree burn.

C. Full-thickness skin destruction: Full-thickness burns involve all layers of the skin (epidermis, dermis, and subcutaneous tissue). The skin appears dry, pale, and hard, and there is no pain due to nerve damage.

D. Deep partial-thickness skin destruction: Deep partial-thickness burns affect the epidermis and deeper layers of the dermis, causing blisters and pain. However, the lack of pain in this case, combined with the dry, pale, and hard skin, suggests a full-thickness burn rather than a deep partial-thickness one.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Prepare to restrain the patient: Restraint should never be used during a seizure as it can cause injury to both the client and the nurse. The primary focus should be on protecting the client from harm without restraining them.

B. Keep an oxygen setup at the bedside: During or after a seizure, the client may experience respiratory distress. Keeping oxygen at the bedside ensures quick access to airway support if needed. This is important for maintaining oxygenation during a seizure.

C. Provide a suction setup at the bedside: A suction setup is crucial in case the client vomits or has secretions that could obstruct the airway. Suctioning can help maintain airway patency and reduce the risk of aspiration during or after a seizure.

D. Place the bed in the lowest position: Placing the bed in the lowest position reduces the risk of injury if the client falls or moves unexpectedly during a seizure. This is a critical safety measure to prevent harm.

E. Elevate the side rails near the head when the client is in bed: Elevating the side rails helps prevent the client from falling out of bed during a seizure. This provides a protective barrier, reducing the risk of injury from falls.

A. Increased heart rate B. Increased deep tendon reflexes C. Pulse oximetry 96% D. Widening pulse pressure

Correct Answer is A

Explanation

A. Increased heart rate: In hypovolemic shock, the body compensates for decreased blood volume by increasing the heart rate to maintain cardiac output and perfusion to vital organs. This is one of the first signs of shock, especially in response to blood loss or fluid depletion.

B. Increased deep tendon reflexes: Increased deep tendon reflexes are not a typical sign of hypovolemic shock. They are more commonly associated with neurological conditions or electrolyte imbalances, not circulatory shock.

C. Pulse oximetry 96%: A pulse oximetry reading of 96% is within the normal range and does not suggest hypovolemic shock. In shock, oxygen saturation would typically decrease, especially if perfusion is compromised, leading to hypoxia and lower oxygen levels.

D. Widening pulse pressure: A widening pulse pressure is generally associated with conditions such as increased intracranial pressure or head injury. In hypovolemic shock, pulse pressure tends to narrow due to a decrease in stroke volume and compensatory mechanisms.

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When assessing a client who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale and hard. The client states that the burn is not painful. What term would the nurse use to document the burn depth?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Correct Answer is A

Explanation

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