Nokea
The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document?
- A. Superficial partial thickness.
- B. Deep partial thickness.
- C. Full thickness.
- D. First degree.
Correct Answer: B
Rationale: Blistered, mottled red skin with edema indicates deep partial-thickness burns, affecting the dermis with severe pain. Superficial partial thickness has no blisters, full thickness is painless and leathery, and first degree is superficial with erythema.
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After reviewing the medical orders, which of the following is essential for the nurse to assess preoperatively?
- A. The client's face for skin lesions
- B. The client of the last dose of anticoagulant
- C. The client's right eye for drainage
- D. The client's left eye for signs of strain
Correct Answer: B
Rationale: Assessing the last anticoagulant dose is critical to prevent bleeding during surgery.
A client who has just been diagnosed with psoriasis asks the nurse what should be done to prevent family members from getting the condition. What should the nurse include when responding to this question?
- A. Showering daily with antiseptic soap should be sufficient.
- B. Wearing clothing over the affected part and washing clothes separately from the rest of the family are all that is necessary.
- C. Psoriasis is not contagious, so no special precautions are necessary.
- D. Psoriasis is transmitted primarily by direct contact with the skin.
Correct Answer: C
Rationale: Psoriasis is a non-contagious autoimmune condition, so no precautions are needed to prevent transmission to family members.
The client experiences local burning and stinging when mafenide cream is applied to treat a burn injury. Which action should be taken by the nurse?
- A. Remove any mafenide that has been applied.
- B. Immediately notify the health care provider.
- C. Double-check the concentration of mafenide.
- D. Inform the client that this is a normal response.
Correct Answer: D
Rationale: Burning or stinging with application of mafenide (Sulfamylon) is a normal response. Mafenide is bacteriostatic and used to reduce gram-negative and gram-positive organisms present in burned tissues. Removal of mafenide or notifying the HCP is unnecessary. Mafenide cream is supplied in 11.2% cream; there are no other concentrations available.
What is the most common profile of a client with malignant melanoma?
- A. An African American client with dark skin and dark hair
- B. A Scandinavian client with freckles and blue eyes
- C. A Mexican client with tan skin and dark brown hair
- D. A Caucasian client with brown hair and brown eyes
Correct Answer: B
Rationale: Fair-skinned individuals with freckles are at higher risk for melanoma.
When describing the examination procedure to the client, which statement by the nurse is most accurate?
- A. You'll read words that are the size of newsprint.
- B. You'll read letters from a distance of 20 feet to mears.
- C. You'll look at a color picture and identify an image.
- D. You'll look at a screen and tell me when an object appears.
Correct Answer: B
Rationale: The Snellen chart involves reading letters from 20 feet to assess visual acuity.