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What is the most appropriate nursing action?
- A. Report this sign immediately.
- B. Place a warm towel over the extremities.
- C. Gently sponge with cool water.
- D. Medicate for pain.
Correct Answer: D
Rationale: A purple flush in severe frostbite indicates returning sensation, causing pain that requires medication.
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How does the nurse classify this burn when documenting?
- A. First-degree
- B. Second-degree superficial
- C. Second-degree deep dermal
- D. Third-degree
Correct Answer: B
Rationale: A second-degree superficial burn is characterized by pink, moist, blistered skin with pain, indicating tissue viability.
With what is this symptom associated?
- A. Scabies
- B. Pediculosis capitis
- C. Tinea corporis
- D. Eczema
Correct Answer: A
Rationale: Intense itching, especially at night in the axilla and between fingers, is characteristic of scabies.
The nurse assesses the total body surface area (TBSA) percentage burn as __%.
Correct Answer: 26
Rationale: For a 5-year-old, the TBSA burn is calculated as 26% based on the Burn Size Estimation Table (upper/lower arm 5.5%, hand 2.5%, anterior trunk 13%, genital area 1%, half thigh 4%).
What should the nurse monitor for very closely in the burn victim?
- A. Increasing intracranial pressure
- B. Reduced urine output
- C. Eschar formation
- D. Fluid overload
Correct Answer: B
Rationale: Reduced urine output indicates altered renal function due to fluid shifts in severe burns, requiring close monitoring.
What would the nurse teach parents to do in order to avoid diaper rash?
- A. Use ointments.
- B. Keep perineum covered at all times.
- C. Use disposable diapers.
- D. Avoid plastic bloomers or pants.
- E. Change diaper frequently.
Correct Answer: A,C,D,E
Rationale: Using ointments, disposable diapers, avoiding plastic pants, and frequent diaper changes prevent diaper rash by keeping the skin dry and protected.