Ati nur211 mobility exam
Ati nur211 mobility exam ( 29 Questions)
A nurse is assessing a client who has been brought to the emergency room with burn injuries. Which of the following findings should the nurse recognize as indicative of a deep partial-thickness burn?
Deep partial-thickness burns, also known as second-degree burns, typically present with a pink or red color and blisters. These burns extend into the deeper layers of the dermis but do not affect the full thickness of the skin. The presence of blisters indicates that the burn has penetrated the epidermis and reached the dermis, causing fluid accumulation between these layers.
The burned area being yellow in color with severe edema is more indicative of a full-thickness burn or a severe infection. Full-thickness burns (third-degree burns) often appear white, brown, or black and are characterized by a leathery texture. Severe edema can occur with any burn but is not specific to deep partial-thickness burns.
A burned area that is red in color with eschar present suggests a full-thickness burn. Eschar is a hard, leathery crust that forms over a full-thickness burn as the skin dies and coagulates. This type of burn destroys both the epidermis and dermis, and the presence of eschar indicates a more severe injury than a deep partial-thickness burn.
A burned area that is black in color and pain is absent is characteristic of a full-thickness burn. In these burns, the nerve endings are destroyed, leading to a lack of pain sensation. The black color indicates necrosis of the skin and underlying tissues, which is not seen in deep partial-thickness burns.
Choice A Reason:
Deep partial-thickness burns, also known as second-degree burns, typically present with a pink or red color and blisters. These burns extend into the deeper layers of the dermis but do not affect the full thickness of the skin. The presence of blisters indicates that the burn has penetrated the epidermis and reached the dermis, causing fluid accumulation between these layers.
Choice B Reason:
The burned area being yellow in color with severe edema is more indicative of a full-thickness burn or a severe infection. Full-thickness burns (third-degree burns) often appear white, brown, or black and are characterized by a leathery texture. Severe edema can occur with any burn but is not specific to deep partial-thickness burns.
Choice C Reason:
A burned area that is red in color with eschar present suggests a full-thickness burn. Eschar is a hard, leathery crust that forms over a full-thickness burn as the skin dies and coagulates. This type of burn destroys both the epidermis and dermis, and the presence of eschar indicates a more severe injury than a deep partial-thickness burn.
Choice D Reason:
A burned area that is black in color and pain is absent is characteristic of a full-thickness burn. In these burns, the nerve endings are destroyed, leading to a lack of pain sensation. The black color indicates necrosis of the skin and underlying tissues, which is not seen in deep partial-thickness burns.