The nurse recalls which description as the most accurate regarding a deep partial-thickness burn

N123 Burn Injuries

A nurse is providing care to a patient with a partial-thickness burn. Which clinical manifestation does the nurse anticipate?
1
Coagulation necrosis
2
Damage to all skin elements
3
Destruction of all nerve endings
4
Damage to epidermis and dermis involvin

4
Burns may be superficial or deep thickness. Partial-thickness burns involve damage to the epidermis and dermis at varying depths. Coagulation necrosis, damage to all skin elements, and the destruction of nerve endings are observed in full-thickness burn

A nurse working in a burn unit identifies that which patients are at an increased risk of developing venous thromboembolism? Select all that apply.
1
Young age
2
Morbid obesity
3
Prolonged immobility
4
Upper-extremity burns
5
First-degree burn of a finger

2, 3
The risk factors for the development of venous thromboembolism a burn patient are morbid obesity and prolonged immobility. These patients may develop stasis of blood due to immobility, which results in development of venous thromboembolism. Young age

Which complication is caused by an electric burn?
1
Myoglobinuria
2
Systemic toxicity
3
Protein hydrolysis
4
Metabolic asphyxiation

1
Electric burns often cause the release of myoglobin from injured muscle tissues into circulation, causing myoglobinuria. Systemic toxicity and protein hydrolysis results from chemical injury. Smoke and inhalational injury results in metabolic asphyxiati

A nurse is teaching a group of parents how to reduce the risk for injury related to burns. Which statement by a participant indicates effective learning?
1
"Frayed wires are OK to use at home."
2
"I should hold regular home fire exit drills."
3
"I should

2
Regular home fire exit drills ensure the family knows the primary escape routes in case of any flame accidents at home. Frayed wires lack protective insulation, and contact may result in electrical injuries. Gasoline or kerosene should never be used to

According to the Rule of Nines for calculating the percentage of burns, the nurse should assign what percentage to a burn in the genitalia?
1
1%
2
4.5%
3
9%
4
18%

1
The Rule of Nines is a formula used for calculating the percentage of burns during initial assessment of a burn patient. The genitals are assigned 1%. Burns in the head and arms are assigned 4.5% each. Burns on the lower extremities are assigned 9% each

When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply.
1
Increasing hoarseness
2
Location of contact points
3
Leathery white charred skin
4
Darkened oral or nasal mem

1, 4, 5
In inhalation burns, either the respiratory tract is exposed to intense fumes or heat, or the patient inhales noxious chemicals or smoke. Increasing hoarseness is seen due to irritation of the upper airway during inhalation and the laryngeal edema

A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin does the nurse inspect for damage?
1
Epidermis only
2
Muscle and bone
3
Epidermis and dermis
4
Epidermis, dermis, and subcutaneous tissue

3
In a second-degree, or partial-thickness, burn, both the epidermis and dermis are damaged. A first-degree superficial burn, such as sunburn, involves only the epidermis. A third- or fourth-degree full-thickness burn may involve muscle and bone. A third-

Which type of burn injury occurs on the layers of subcutaneous fat, muscle, or deeper structures?
1
Sunburn
2
Full thickness burn
3
Deep partial thickness burn
4
Superficial partial thickness burn

2
A full thickness burn is a burn of the layers of subcutaneous fat, muscle, or deeper structures. A superficial partial thickness burn is a burn of the epidermis layer; a sunburn is a type of superficial partial thickness burn. A deep partial thickness b

A patient is brought to the emergency department (ED) with severe burns on the legs and feet. Which factors lead the nurse to believe the patient may have full-thickness burns? Select all that apply.
1
Touch sensation is impaired.
2
Blanching with pressur

1, 3, 5
Touch sensation is impaired due to impaired nerve endings in full-thickness burns. Lack of blanching with pressure is observed, because all skin elements are destroyed. Wounds appear waxy white, dark brown, or charred in full-thickness burns, beca

Which fluid and electrolyte change occurs during the early emergent phase of burn injury?
1
Increased excretion of urine
2
Increased colloidal osmotic pressure
3
Return of interstitial fluid to the vascular space
4
Movement of sodium and water into inters

4
After the burn, in the emergent phase, the capillary walls become more permeable, causing the movement of sodium, water, and plasma proteins into the interstitial spaces and surrounding tissues. An increased excretion of urine and the return of intersti

A nurse notes decreased reflexes during the physical assessment of a patient who was admitted with a burn injury. What is the likely cause for this clinical manifestation?
1
Decreased water levels
2
Increased sodium levels
3
Increased albumin levels
4
Dec

4
A decreased level of potassium, known as hypokalemia, results from the loss of potassium from the burn wounds. Clinical manifestations include muscle weakness, leg cramps, paresthesias, and decreased reflexes. Decreased levels of water and increased lev

A nurse is providing care to a patient who suffered burns to the perineum. For what is the patient at risk of developing?
1
Infection to the respiratory tract
2
Infection from urine contamination
3
Infection to the vascular and nerve supply
4
Infection be

2
The perineum is the part of the body occupied by urogenital passages and the rectum. A patient with burns to the buttocks or perineum is at an increased risk for infection from urine or feces contamination. A patient with burns to the face and neck is s

The ambulance reports that it is transporting a patient to the emergency department who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect?
1
Severe pain, blisters, and blanching with pressure
2
Pain, m

4
With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial

Which statement made by a student nurse regarding clinical manifestations associated with severe burns indicates the need for further education?
1
"The patient's altered mental status is due to hypoxia."
2
"The patient with larger burns may develop paraly

4
Which statement made by a student nurse regarding clinical manifestations associated with severe burns indicates the need for further education?
1
"The patient's altered mental status is due to hypoxia."
2
"The patient with larger burns may develop para

A patient presents in the emergency department with a bright red burned area, with moist, red, shiny vesicles and blister formation. The patient reports severe pain when the site is exposed to air. Which type of burn will the nurse document in the patient

4
A second-degree burn manifests as a bright red burned area with moist, red, shiny vesicles and blister formation. There is also severe pain upon exposure to air. In first-degree burns, there is erythema, blanching on application of pressure, and no vesi

A patient arrives in the burn unit with erythema, pain, and mild swelling following a burn injury while cooking. Based on the wound observation and patient symptoms, the nurse should document the depth of the burn as what?
1
First degree
2
Second degree
3

1
Burns which are painful, erythematous, and associated with mild swelling are first-degree burns. Second-degree burns are associated with vesicles and appear shiny. Third- and fourth-degree burns are white, waxy, and are insensitive to pain due to nerve

What are the clinical manifestations of a lower airway lung injury associated with burns? Select all that apply.
1
Edema
2
Blisters
3
Dyspnea
4
Wheezing
5
Altered mental status

3, 4, 5
Dyspnea, wheezing, and an altered mental status are manifestations of a lower airway lung injury associated with burns. Edema and blisters are manifestations of an upper airway lung injury associated with burns.
Text Reference - p. 452

The nurse is reviewing the fluid and electrolyte shifts that occur during burn injury. Which of these occur during the emergent stage of a burn injury? Select all that apply.
1
Movement of potassium into the cells.
2
Adherence of albumin to vascular walls

3, 4, 5
During the emergent phase, sodium and water rapidly shift to the interstitial spaces and remain there until edema formation ceases. The hematocrit is elevated because of hemoconcentration related to fluid loss. Fluid also moves to areas that norma

Which burn injury results in tissue anoxia?
1
Thermal burn
2
Chemical burn
3
Electrical injury
4
Smoke and inhalational injury

3
Electrical injury causes tissue anoxia due to nerve damage and nerve death. The injury sustained by a thermal burn is dependent on the temperature of the burning agent and the length of exposure. Chemical burns can cause tissue damage and eyes can be in

A nurse is providing care to a patient who was admitted to the hospital with third-degree burns. Which clinical manifestations should the nurse anticipate? Select all that apply.
1
Erythema
2
Fluid-filled vesicles
3
Hard, leathery skin
4
Insensitivity to

3, 4
Third-degree burns cause full-thickness skin destruction. Clinical manifestations include hard, leathery skin and insensitivity to pain due to nerve destruction. Erythema is observed in first-degree burns. Second-degree burns are characterized by flu

The nurse recalls which description as the most accurate regarding a deep partial-thickness burn?
1
Painful with weeping blisters
2
Minimal damage to the epidermis
3
Charring visible in the deepest areas
4
Necrotic tissue through all layers of the skin

A deep partial-thickness burn involves the epidermal and dermal layers of the skin. It is characterized by a wet, shiny, weeping surface marked by blisters and is painful and very sensitive to the touch. Necrosis and charring are seen with a full-thicknes

A nurse is assessing a patient who was injured using heavy industrial cleanser while working at a factory. For which complications will the nurse monitor? Select all that apply.
1
Hypoxia
2
Liquefaction
3
Tissue anoxia
4
Protein hydrolysis
5
Metabolic aci

2, 4
A chemical burn results from contact with an alkali, such as an industrial cleanser. When the alkalis come in contact with skin, they adhere to the tissue, resulting in protein hydrolysis and liquefaction. Hypoxia occurs in smoke and inhalational inj

A patient arrives at the burn unit with large burns on the chest and abdomen. While assessing the patient, the nurse suspects full-thickness burns. What findings are likely to be found in the patient with full-thickness burns? Select all that apply.
1
The

1, 2, 5
The patient with severe burns is likely to be in shock from hypovolemia and may have low blood pressure. The patient experiences shivering as a result of chilling that is caused either by heat loss, anxiety, or pain. The patient with a larger burn

A nurse is caring for a patient who has sustained burns over the entire surfaces of both arms, the anterior trunk, and the right leg. The nurse uses the rule of nines to estimate the percentage of the burn surface area as:
1
27%
2
36%
3
54%
4
72%

3
The "rule of nines" is a method used to determine the body surface area (BSA) of a burn injury. It assigns 9% to each arm, 9% to the head, 18% to the anterior torso, 18% to the posterior torso, 18% to each leg, and 1% to the genitals. The other answer o

While assessing a patient with severe burns, the nurse suspects hypokalemia. What possible causes should the nurse evaluate? Select all that apply.
1
Vomiting
2
Renal failure
3
Prolonged gastrointestinal (GI) suction
4
Adrenal insufficiency
5
IV therapy w

1, 3, 5
Hypokalemia occurs due to lack of potassium. Excessive vomiting causes loss of body fluids leading to a loss of potassium. Prolonged GI suction also causes fluid loss and decreases potassium levels. The IV therapy without potassium fails to compen

A patient who sustained burns in a house fire develops a paralytic ileus. What does the nurse suspect to be the cause of this complication?
1
Sepsis
2
Enteral feedings
3
Opioid analgesics
4
Increased gastric acid secretion

1
Paralytic ileus is caused when the burn patient experiences sepsis. Enteral feedings may cause the patient to experience diarrhea. Constipation is a side effect for opioid analgesics, which are required for pain management. Curling's ulcer occurs as a r

A patient is admitted to the burn unit with second-degree thermal burns. Which characteristics of a second-degree thermal burn should the nurse expect to find during the physical assessment? Select all that apply.
1
Fluid-filled vesicles
2
Severe pain
3
M

1, 2, 3
Second-degree burns show epidermal and dermal involvement to varying depths. These burn injuries are characterized by fluid-filled vesicles that are erythematous, glossy, and damp. The patient may complain of severe pain caused by nerve injury. Mi

A patient with a flash burn injury is admitted to the emergency department. The nurse notes a bright red area with blisters that blanches with the application of pressure. The patient also reports severe pain when the burn is exposed to air. Which type of

3
A bright red area with blisters, blanching upon pressure, and severe pain in the patient indicates a deep partial-thickness burn. Superficial and superficial partial-thickness burns are characterized by erythema, but no blisters, with pain and mild swel

Which clinical manifestations are observed in a patient in the emergent phase of a burn injury? Select all that apply.
1
Increased appetite
2
Increased heart rate
3
Increased urine output
4
Decreased respiratory rate
5
Decreased blood pressure

2, 5
During the emergent phase of a burn injury, the patient exhibits tachycardia and hypotension. Other clinical manifestations during this phase include a loss of appetite, a decreased urine output, and tachypnea.
Text Reference - p. 464

A nurse is assessing a patient who was burned after contact with gasoline. For which complication does the nurse monitor?
1
Liquefaction
2
Systemic toxicity
3
Protein hydrolysis
4
Severe metabolic acidosis

2
Gasoline is an organic compound that causes chemical burns. This compound produces systemic toxicity in patients. Liquefaction and protein hydrolysis occur due to chemical burns resulting from alkalis. Electrical injury results in severe metabolic acido

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation?
1
Blisters
2
Reddening of the skin
3
Destruction of all skin lay

2
The clinical appearance of superficial partial-thickness burnsincludes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.
Text Reference - p. 454

A nurse is assessing a patient admitted to the emergency department after the inhalation of toxic chemicals. Which finding indicates a lower airway injury?
1
Blisters
2
Singed nasal hairs
3
Pulmonary edema
4
Acute respiratory distress syndrome

2
Singed nasal or facial hair is one of the manifestations of a lower airway injury, involving the trachea, bronchioles, and alveoli. Blisters occur in an upper airway injury. Pulmonary edema occurs in a lower airway injury, but it is only seen 12 to 24 h

Following fluid resuscitation, which parameter indicates a stable condition?
1
Systolic blood pressure (BP) more than 90 mm Hg
2
Urine output 0.5 mL/kg/hr
3
Heart rate more than 120 beats/minute
4
Mean arterial pressure (MAP) less than 65 mm Hg

1
Hourly assessments of the adequacy of fluid resuscitation are best made using clinical parameters. Urine and cardiac parameters are most commonly used. Urine output should be 0.5 to 1 mL/kg/hr and 75 to 100 mL/hr for an electrical burn patient with evid

A patient who escaped from a burning building, which was enclosed with no ventilation, is brought to the emergency department. The patient is confused, has difficulty breathing, and has nasal burns. Which condition does the nurse suspect?
1
Pulmonary edem

2
A patient who was trapped in an enclosed burning building with no ventilation and is exhibiting confusion, dyspnea, and nasal burns is most likely experiencing a lower airway burn injury. Pulmonary edema may occur but not until 12 to 24 hours after the

A nurse is planning care for a patient with a 30% body surface area burn injury. Which statement regarding the nutritional status of this patient is true?
1
Decreased protein intake will decrease the chance of renal complications.
2
Maintaining a hypermet

4
A burn injury causes a hypermetabolic state, resulting in protein and lipid catabolism that can inhibit wound healing. Therefore the patient with a burn injury requires increased calories and protein to enable the healing process. Protein intake in the

A patient with a burn injury is brought to the emergency department. The nurse notes white, leathery skin, dysrhythmias, and a loss of consciousness. Which type of burn injury does the nurse suspect?
1
Thermal
2
Electrical
3
Chemical
4
Inhalational

2
Electrical burns occur from the intense heat of an electrical current. Electrical burns present with dry and leathery skin, dysrhythmia, and a loss of consciousness. Thermal burns occur due to hot liquids or flames, resulting in skin injuries ranging fr

A patient is admitted to the burns ward with deep partial-thickness burns on the hands. What characteristics is the nurse likely to find when performing examination of the wound? Select all that apply.
1
Wounds are painless.
2
Wounds are wet and shiny.
3

2, 3, 4
Partial-thickness wounds are wet and shiny due to serous exudates. These wounds are painful to touch due to nerve injury. Wounds appear pink to cherry-red. Wounds are painless in full-thickness burns due to nerve destruction. Wounds appear black a

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being?
1
18%
2
22.5%
3
27%

2
Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has

What is the appearance of a deep partial thickness burn?

Which best describes a partial thickness burn?

What are the signs of a partial thickness burn?

Which structure of the skin would the nurse identify as affected in a deep partial thickness burn?