Nokea
The nurse who documents the burn injury is accurate in identifying the full-thickness burns as having what appearance?
- A. White and leathery
- B. Pink and blistered
- C. Red and painful
- D. Mottled and wet
Correct Answer: A
Rationale: Full-thickness burns appear white, leathery, and painless due to nerve destruction.
You may also like to solve these questions
The long-term care nurse has received the a.m. shift report. Which client should the nurse assess first?
- A. The client who has not had a bowel movement today.
- B. The client who needs the indwelling catheter changed.
- C. The client with periorbital skin lesions.
- D. The client with a stage I pressure ulcer.
Correct Answer: C
Rationale: Periorbital skin lesions (e.g., herpes zoster ophthalmicus) risk eye complications, requiring urgent assessment. Constipation, catheter changes, and stage I ulcers are less acute.
Before the client leaves the emergency department, which nursing instruction is most appropriate?
- A. Advise the client to limit dietary intake of fluids.
- B. Tell the client to sleep in a recliner or with the head up.
- C. Show the client how to take the carotid pulse at hourly intervals.
- D. Warn the client to avoid blowing the nose for several hours.
Correct Answer: D
Rationale: Avoiding nose blowing prevents dislodging clots and restarting bleeding.
A woman who has herpes simplex 1 (HSV1) around the mouth and nose asks the nurse if she can give the sores to her husband. What should the nurse include when answering this client?
- A. Herpes simplex 1 (HSV1) is a fever blister and is not contagious.
- B. She should not kiss her husband or anyone else because it can be transmitted to susceptible persons.
- C. Fever blisters are seen only in persons who have fevers.
- D. The virus is transmitted through coughing and sneezing.
Correct Answer: B
Rationale: HSV1 is contagious and can be transmitted through direct contact, such as kissing, especially during active outbreaks.
Which statement by the client diagnosed with chickenpox indicates that the client understands the teaching?
- A. I should put rubbing alcohol on the lesions twice a day.'
- B. I should not scratch myself if at all possible. It might lead to scarring.'
- C. I can go to work when my lesions have all disappeared.'
- D. I need to take all my antibiotics no matter how I feel.'
Correct Answer: B
Rationale: Avoiding scratching prevents scarring and infection in chickenpox. Alcohol is harmful, contagiousness persists post-lesions, and antibiotics are not used.
The health department nurse is caring for the client who has leprosy (Hansen’s disease). Which assessment data indicate the client is experiencing a complication of the disease?
- A. Elevated temperature at night.
- B. Brownish-black discoloration to the skin.
- C. Reduced skin sensation in the lesions.
- D. A high count of mycobacteria in the culture.
Correct Answer: C
Rationale: Reduced sensation in lesions indicates nerve damage, a leprosy complication. Night fevers, discoloration, and bacterial load are less specific.