Pearson Burns Study Guide Test.

Pearson Burns Study Guide Test. a (Rationale Deep partial-thickness burns occur when the skin is burned into the dermis. The hair follicles, sebaceous glands, and sweat glands are intact. The skin is pale and waxy, and dry (like tissue paper); large blisters develop. The burned areas are less painful and have areas of decreased sensation. Superficial burns are burns to the epidermis. The skin is intact and skin color is pink to bright red in color. Edema is present over the burned area, and healing takes place in 3 to 6 days. With full-thickness burns, all layers of the skin, subcutaneous tissue, connective tissue, muscle, and bone are involved in the burn. The wound surface is dry, with a leathery feel, and is firm to touch. The skin is pale, waxy yellow, brown, mottled, or nonblanching red; there is no sensation or pain. Superficial partial-thickness burns are bright red and moist. There is a blister formation and blanching on p - CORRECT ANSWER The nurse is caring for a client with a burn. The assessment reveals that there are large blisters that are dry like tissue paper with areas of decreased sensation. The burns are pale with a waxy appearance. Which type of burn will the nurse document in the client's medical record? a Deep partial thickness b Superficial c Full thickness d Superficial partial thickness b (Rationale The extent of burns is not how many limbs are involved; it is the percentage of the body that is burned. The extent of burns is determined by calculating BSA; therefore, the nurse educator would not question this statement. The BSA is measured as a percentage and will give a better understanding of how much of the body is affected by the burn. The extent of burns is calculated by the Rule of Nines; therefore, the nurse educator would not question this statement. The Rule of Nines measures the BSA by dividing the body into five surface areas: the head, trunk, arms, legs, and perineum. Each surface is assigned a number that is a multiple of nine. The amount is totaled and represents the BSA that is affected. The extent of burns can be calculated by the Lund and Browder method; therefore, the nurse educator would not question this statement. The Lund and Browder method determines the BSA by measuring - CORRECT ANSWER A nurse educator is educating a student on burns. Which statement made by the student would indicate that further education is necessary? a "The extent of burns is calculated by the Rule of Nines." b "The extent of burns is how many limbs are involved." c "The extent of burns can be calculated by the Lund and Browder method." d "The extent of burns is expressed as a percentage of body surface area (BSA)." c (Rationale Fluid resuscitation is a priority in the first 24 hours after a burn to prevent the onset of shock and system collapse; urine output is the most readily available and reliable indicator for determining the adequacy of fluid replacement. Pain is a high priority, but measures to preserve life must be a priority. Assessing for infection is important. However, during the shock phase, measures to preserve life must be a priority. Hourly ROM cannot occur until after the client is stabilized.) - CORRECT ANSWER A client is being treated for second- and third-degree burns over 60% of the body. Fourteen hours later, the client is receiving a lactated Ringer solution at 200 mL/hr. Which intervention is a priority at this time?