Question 1

While assessing the feet and ankles of an older adult client,the nurse presses a finger into the client's skin in order to create an indentation.For what is the nurse assessing?

Accepted Answer

A) Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Sacral edema is swelling around the hips and buttock region. Periorbital edema is swelling around the eyes.
B) Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Sacral edema is swelling around the hips and buttock region. Periorbital edema is swelling around the eyes.
C) Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Sacral edema is swelling around the hips and buttock region. Periorbital edema is swelling around the eyes.
D) Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Sacral edema is swelling around the hips and buttock region. Periorbital edema is swelling around the eyes.

Question 2

A client has superficial burns on the hand from boiling water.What can the nurse suggest that the client use to help with the healing of these burns?

Accepted Answer

A) The nurse should provide information on home remedies that could help in the healing of the client's burns. Aloe vera gel is useful to treat superficial burns. Evening primrose oil is helpful with atopic eczema. Chamomile is helpful with skin inflammation. Vitamin C is not recommended to help with the healing of burns.
B) The nurse should provide information on home remedies that could help in the healing of the client's burns. Aloe vera gel is useful to treat superficial burns. Evening primrose oil is helpful with atopic eczema. Chamomile is helpful with skin inflammation. Vitamin C is not recommended to help with the healing of burns.
C) The nurse should provide information on home remedies that could help in the healing of the client's burns. Aloe vera gel is useful to treat superficial burns. Evening primrose oil is helpful with atopic eczema. Chamomile is helpful with skin inflammation. Vitamin C is not recommended to help with the healing of burns.
D) The nurse should provide information on home remedies that could help in the healing of the client's burns. Aloe vera gel is useful to treat superficial burns. Evening primrose oil is helpful with atopic eczema. Chamomile is helpful with skin inflammation. Vitamin C is not recommended to help with the healing of burns.

Question 3

An older adult client complains of having dry skin.Which items would support this client's complaint? Select all that apply.

Accepted Answer

A) The epidermal cells of the older person contain less moisture. This contributes to a dry, rough skin appearance. Reduced fluid intake and poor nutrition could cause dry skin. Another reason is the decline in moisture due to advanced age. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult's thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.
B) The epidermal cells of the older person contain less moisture. This contributes to a dry, rough skin appearance. Reduced fluid intake and poor nutrition could cause dry skin. Another reason is the decline in moisture due to advanced age. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult's thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.
C) The epidermal cells of the older person contain less moisture. This contributes to a dry, rough skin appearance. Reduced fluid intake and poor nutrition could cause dry skin. Another reason is the decline in moisture due to advanced age. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult's thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.
D) The epidermal cells of the older person contain less moisture. This contributes to a dry, rough skin appearance. Reduced fluid intake and poor nutrition could cause dry skin. Another reason is the decline in moisture due to advanced age. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult's thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.
E) The epidermal cells of the older person contain less moisture. This contributes to a dry, rough skin appearance. Reduced fluid intake and poor nutrition could cause dry skin. Another reason is the decline in moisture due to advanced age. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult's thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.

Question 4

A nurse working at a burn center is caring for a client with an electrical burn.According to the American Burn Association,how would this burn be classified?

Accepted Answer

A) According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.
B) According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.
C) According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.
D) According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.

Question 5

After a skin graft procedure to the leg,a client is returned to the burn care unit.Based on this data,which action by the nurse is appropriate?

Accepted Answer

A) Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.
B) Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.
C) Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.
D) Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.

Question 6

A client with a burn injury is prescribed mechanical debridement of the wounds.Based on this data,which should the nurse include in the client's plan of care? Select all that apply.

Accepted Answer

A) Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement.
B) Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement.
C) Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement.
D) Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement.
E) Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement.

Question 7

The nurse is providing care to a client who is experiencing skin inflammation and pruritus.Which medication prescriptions does the nurse anticipate for this client? Select all that apply.

Accepted Answer

A) Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and Gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and Desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.
B) Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and Gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and Desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.
C) Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and Gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and Desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.
D) Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and Gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and Desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.
E) Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and Gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and Desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.

Question 8

A nurse is caring for a client who is scheduled to undergo diagnostic testing to determine the cause of dermatitis.When educating the client about diagnostic testing,which statement by the nurse is appropriate?

Accepted Answer

A) In patch testing, an adhesive patch with common allergens is placed on the client's back. The patch from the patch test is usually removed after 48 to 72 hours. Skin prick and skin injection tests are used to test for immediate reactions. The client should not shower or exercise to the point of perspiring while the patch from the patch test is in place.
B) In patch testing, an adhesive patch with common allergens is placed on the client's back. The patch from the patch test is usually removed after 48 to 72 hours. Skin prick and skin injection tests are used to test for immediate reactions. The client should not shower or exercise to the point of perspiring while the patch from the patch test is in place.
C) In patch testing, an adhesive patch with common allergens is placed on the client's back. The patch from the patch test is usually removed after 48 to 72 hours. Skin prick and skin injection tests are used to test for immediate reactions. The client should not shower or exercise to the point of perspiring while the patch from the patch test is in place.
D) In patch testing, an adhesive patch with common allergens is placed on the client's back. The patch from the patch test is usually removed after 48 to 72 hours. Skin prick and skin injection tests are used to test for immediate reactions. The client should not shower or exercise to the point of perspiring while the patch from the patch test is in place.

Question 9

A client who sustained burns to both lower extremities complains to the nurse about feeling frustrated by not being able to provide self-care.Which nursing diagnosis would be appropriate for the client at this time?

Accepted Answer

A) The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low-self-esteem, ineffective coping, or anxiety.
B) The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low-self-esteem, ineffective coping, or anxiety.
C) The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low-self-esteem, ineffective coping, or anxiety.
D) The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low-self-esteem, ineffective coping, or anxiety.

Question 10

A client is evaluated after suffering severe burns to the torso and upper extremities.The nurse notes edema at the burned areas.Which best describes the underlying cause for this manifestation?

Accepted Answer

A) Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments.
B) Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments.
C) Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments.
D) Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments.

Question 11

An older adult client with severe burns over more than half of the body has an indwelling catheter.When evaluating the client's intake and output,which should be taken into consideration?

Accepted Answer

A) The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.
B) The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.
C) The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.
D) The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.

Question 12

The nurse is evaluating the adequacy of the burn-injured client's nutritional intake.Which laboratory value is the best indicator of nutritional status?

Accepted Answer

A) Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent upon the fluid status.
B) Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent upon the fluid status.
C) Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent upon the fluid status.
D) Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent upon the fluid status.

Question 13

A middle-age adult client states to the nurse "I do want to have liver spots like my parents did as they got older".Which instruction by the nurse is appropriate?

Accepted Answer

A) Small areas of hyperpigmentation, or liver spots, occur as an age-related skin change because of hyperplasia of melanocytes in sun-exposed areas. The nurse should instruct the client to avoid the sun or use a sunscreen to reduce skin damage. The nurse should not instruct the client to spend at least 15 minutes each day in the sun to avoid skin damage. The intake of dietary fat or calcium will not affect the development of liver spots.
B) Small areas of hyperpigmentation, or liver spots, occur as an age-related skin change because of hyperplasia of melanocytes in sun-exposed areas. The nurse should instruct the client to avoid the sun or use a sunscreen to reduce skin damage. The nurse should not instruct the client to spend at least 15 minutes each day in the sun to avoid skin damage. The intake of dietary fat or calcium will not affect the development of liver spots.
C) Small areas of hyperpigmentation, or liver spots, occur as an age-related skin change because of hyperplasia of melanocytes in sun-exposed areas. The nurse should instruct the client to avoid the sun or use a sunscreen to reduce skin damage. The nurse should not instruct the client to spend at least 15 minutes each day in the sun to avoid skin damage. The intake of dietary fat or calcium will not affect the development of liver spots.
D) Small areas of hyperpigmentation, or liver spots, occur as an age-related skin change because of hyperplasia of melanocytes in sun-exposed areas. The nurse should instruct the client to avoid the sun or use a sunscreen to reduce skin damage. The nurse should not instruct the client to spend at least 15 minutes each day in the sun to avoid skin damage. The intake of dietary fat or calcium will not affect the development of liver spots.

Question 14

A nurse is working in a skilled nursing facility and is performing an assessment on an older adult client.The nurse notes that the client has hypopigmentation of the skin on both hands.Based on this data,which condition does the nurse suspect?

Accepted Answer

A) Hypopigmentation, also known as age spots, is a common finding on the back of the hands of an older adult. Hypopigmentation is caused by hyperplasia of melanocytes. The other findings are incorrect.
B) Hypopigmentation, also known as age spots, is a common finding on the back of the hands of an older adult. Hypopigmentation is caused by hyperplasia of melanocytes. The other findings are incorrect.
C) Hypopigmentation, also known as age spots, is a common finding on the back of the hands of an older adult. Hypopigmentation is caused by hyperplasia of melanocytes. The other findings are incorrect.
D) Hypopigmentation, also known as age spots, is a common finding on the back of the hands of an older adult. Hypopigmentation is caused by hyperplasia of melanocytes. The other findings are incorrect.

Question 15

The nurse is providing care to a client who has a vitamin D deficiency and is at risk for an alteration in skin integrity.The client states,"how can this be? I drink 3 glasses of milk each day." Which response by the nurse is appropriate?

Accepted Answer

A) The skin performs several essential functions. One of these is the synthesis of vitamin D from ultraviolet light. If the client is not exposed to ultraviolet light, there is a risk for developing a vitamin D deficiency. In the United States cow's milk is fortified with vitamin D, and there is nothing to suggest the client is drinking another kind of milk. A loss of melanin does not lead to a decrease in vitamin D. Insufficient protein intake does not cause a vitamin D deficiency.
B) The skin performs several essential functions. One of these is the synthesis of vitamin D from ultraviolet light. If the client is not exposed to ultraviolet light, there is a risk for developing a vitamin D deficiency. In the United States cow's milk is fortified with vitamin D, and there is nothing to suggest the client is drinking another kind of milk. A loss of melanin does not lead to a decrease in vitamin D. Insufficient protein intake does not cause a vitamin D deficiency.
C) The skin performs several essential functions. One of these is the synthesis of vitamin D from ultraviolet light. If the client is not exposed to ultraviolet light, there is a risk for developing a vitamin D deficiency. In the United States cow's milk is fortified with vitamin D, and there is nothing to suggest the client is drinking another kind of milk. A loss of melanin does not lead to a decrease in vitamin D. Insufficient protein intake does not cause a vitamin D deficiency.
D) The skin performs several essential functions. One of these is the synthesis of vitamin D from ultraviolet light. If the client is not exposed to ultraviolet light, there is a risk for developing a vitamin D deficiency. In the United States cow's milk is fortified with vitamin D, and there is nothing to suggest the client is drinking another kind of milk. A loss of melanin does not lead to a decrease in vitamin D. Insufficient protein intake does not cause a vitamin D deficiency.

Question 16

A client has an excoriated skin area with drainage.Which diagnostic test does the nurse anticipate to diagnose the skin lesion?

Accepted Answer

A) Cultures to identify infections may be conducted on tissue samples, on drainage and exudates from lesions, and on serum. Skin biopsies are used to differentiate a benign skin lesion from a skin cancer. A Wood's lamp is used to identify infections through immunofluorescent studies. Patch tests are used to determine allergies.
B) Cultures to identify infections may be conducted on tissue samples, on drainage and exudates from lesions, and on serum. Skin biopsies are used to differentiate a benign skin lesion from a skin cancer. A Wood's lamp is used to identify infections through immunofluorescent studies. Patch tests are used to determine allergies.
C) Cultures to identify infections may be conducted on tissue samples, on drainage and exudates from lesions, and on serum. Skin biopsies are used to differentiate a benign skin lesion from a skin cancer. A Wood's lamp is used to identify infections through immunofluorescent studies. Patch tests are used to determine allergies.
D) Cultures to identify infections may be conducted on tissue samples, on drainage and exudates from lesions, and on serum. Skin biopsies are used to differentiate a benign skin lesion from a skin cancer. A Wood's lamp is used to identify infections through immunofluorescent studies. Patch tests are used to determine allergies.

Question 17

The nurse is concerned that a client is at a high risk for a burn injury.Which data supports the nurse's concern? Select all that apply.

Accepted Answer

A) Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, sense of smell, and hearing, and impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Careless smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury.
B) Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, sense of smell, and hearing, and impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Careless smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury.
C) Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, sense of smell, and hearing, and impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Careless smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury.
D) Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, sense of smell, and hearing, and impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Careless smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury.
E) Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, sense of smell, and hearing, and impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Careless smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury.

Question 18

A nurse educator is teaching a group of student nurses about newborn skin and factors that relate to this concept.Which statement will the educator include in the teaching session?

Accepted Answer

A) The newborn's skin contains more water than an adult's and has loosely attached cells. The newborn's skin is about 40% to 60% thinner than an adult's, which makes the newborn's skin more susceptible to absorption of harmful chemical substances and topical medications. The newborn's skin has less subcutaneous fat compared to adults.
B) The newborn's skin contains more water than an adult's and has loosely attached cells. The newborn's skin is about 40% to 60% thinner than an adult's, which makes the newborn's skin more susceptible to absorption of harmful chemical substances and topical medications. The newborn's skin has less subcutaneous fat compared to adults.
C) The newborn's skin contains more water than an adult's and has loosely attached cells. The newborn's skin is about 40% to 60% thinner than an adult's, which makes the newborn's skin more susceptible to absorption of harmful chemical substances and topical medications. The newborn's skin has less subcutaneous fat compared to adults.
D) The newborn's skin contains more water than an adult's and has loosely attached cells. The newborn's skin is about 40% to 60% thinner than an adult's, which makes the newborn's skin more susceptible to absorption of harmful chemical substances and topical medications. The newborn's skin has less subcutaneous fat compared to adults.

Question 19

A client tells the nurse that flakes of skin come loose with every shampoo.Based on this data,which secondary skin lesion does the nurse suspect the client is experiencing?

Accepted Answer

A) Scales are flakes of greasy, keratinized skin tissue that vary in color from white, gray, to silver. An example of this type of skin lesion is dandruff. Macules and nodules are primary skin lesions. A crust is an area of dry blood, serum, or pus left on the skin surface when vesicles or pustules break.
B) Scales are flakes of greasy, keratinized skin tissue that vary in color from white, gray, to silver. An example of this type of skin lesion is dandruff. Macules and nodules are primary skin lesions. A crust is an area of dry blood, serum, or pus left on the skin surface when vesicles or pustules break.
C) Scales are flakes of greasy, keratinized skin tissue that vary in color from white, gray, to silver. An example of this type of skin lesion is dandruff. Macules and nodules are primary skin lesions. A crust is an area of dry blood, serum, or pus left on the skin surface when vesicles or pustules break.
D) Scales are flakes of greasy, keratinized skin tissue that vary in color from white, gray, to silver. An example of this type of skin lesion is dandruff. Macules and nodules are primary skin lesions. A crust is an area of dry blood, serum, or pus left on the skin surface when vesicles or pustules break.

Question 20

The nurse is providing care to a pediatric client who was admitted to the pediatric intensive care unit (PICU)with a partial-thickness thermal burn.When planning care for this client,which should the nurse consider regarding this type of burn?

Accepted Answer

A) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.
B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.
C) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.
D) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.

Quiz 21: Tissue Integrity