NURS 272 Exam 4 Questions and 100% Correct Answers Which clinical manifestations would the nurse anticipate while caring for a patient with third-degree burns? Select all that apply. 1 Erythema 2 Fluid -filled vesicles 3 Hard, leathery skin 4 Insensitivity to pain 5 Mild to moderate edema ✅3 Hard, leathery skin 4 Insensitivity to pain 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 fluid -filled vesicles and mild to moderate edema. According to the Rule of Nines for calculating the percentage of burns, the nurse would assign which percentage to a burn in the genitalia? 1 1% 2 4.5% 3 9% 4 18% ✅1 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 9% each. Burns on the lower extremities are assigned 18% each. Burns in the chest and back are assigned 18% for each side A patient has sustained burns on the face, neck, and chest. Which additional assessment findings would alert the nurse to an upper airway injury? Select all that apply. 1 Dyspnea 2 Wheezing 3 Hoarseness 4 Singed nasal hair 5 Difficulty in swallowing ✅3 Hoarseness 5 Difficulty in swallowing Upper airway injury may be caused by thermal burns or the inhalation of hot air, steam, or smoke. Hoarseness occurs due to laryngeal edema in the upper airway. Difficulty in swallowing is present due to edema and blistering of the oropharynx in the upper airway. Dyspnea can be observed where there has been an inhalation injury to the lower airway that is caused by breathing toxic chemicals or smoke that affects the trachea, br onchioles, and alveoli. Wheezing is a symptom found in an inhalation injury affecting the lower airway. Singed nasal hair (along with burned facial hair) is an indicator of inhaled burn particles or smoke and is an indicator of lower airway injury. Which factors lead the nurse to believe that a patient with severe burns on the legs and feet may have full -thickness burns? Select all that apply. 1 Touch sensation is impaired. 2 Blanching with pressure is observed. 3 Lack of blanching with pressure is observed. 4 Wounds appear mottled white, pink to cherry red. 5 Wounds appear waxy white, dark brown, or charred. ✅1 Touch sensation is impaired. 3 Lack of blanching with pressure is observed. 5 Wounds appear waxy white, dark brown, or charred. 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 because all skin elements and local nerve endings are destroyed, and coagulation necrosis is present. Blanching with pressure is observed in partial -thickness burns because varying degrees of both the epidermis and dermis are involved, and skin elements of regeneration a re viable. Wounds appear mottled white, pink to cherry red in a partial -
thickness burn. A nurse is planning care for a patient with a 30% body surface area burn injury. Which statement by the nurse regarding the nutritional status of this patient is true? 1 "Maintaining a hypermetabolic state reduces the patient's risk for infection." 2 "Decreased protein intake will decrease the chance of renal complications." 3 "Controlling the temperature of the environment reduces caloric requirements." 4 "A hypermetabolic state results in poor healing and increased protein and lipid needs." ✅4 "A hypermetabolic state results in poor healing and increased protein and lipid needs." 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 bu rn patient should be increased to promote wound healing. Renal function is monitored for complications, which is low risk with burns, because the need for protein is increased. A hypermetabolic state is not desired and is a complication of a burn injury. C ontrolling the temperature of the environment has no effect on caloric requirements. A burn patient with moist, red, shiny vesicles and blister formation reports severe pain when the site is exposed to air. Which type of burn would the nurse document in the patient's medical record? 1 First -degree burn 2 Third -degree burn 3 Fourth -degree burn 4 Second -degree burn ✅4 Second -degree burn 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 vesicle s or blisters. Third - and fourth -degree burns are characterized by dry, waxy, leathery skin that is insensitive to pain. Which manifestations would the nurse expect when admitting a patient with a full thickness thermal burn? 1 Severe pain, blisters, and blanching with pressure 2 Pain, minimal edema, and blanching with pressure 3 Redness, evidence of inhalation injury, and charred skin 4 No pain, waxy white skin, and no blanching with pressure ✅4 No pain, waxy white skin, and no blanching with pressure 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 -
thickness (deep, second -degree) burns. Pain, minimal edema, blanching, and redness occur with partial -thickness (superficial, first -degree) burns When assessing a patient with a second -degree burn, which clinical manifestations would the nurse anticipate? Select all that apply. 1 Blanching 2 Severe pain 3 White, waxy skin 4 Red, shiny vesicles 5 Mild to moderate edema ✅2 Severe pain 4 Red, shiny vesicles 5 Mild to moderate edema Clinical manifestations of second -degree burns include severe pain, the appearance of fluid-filled vesicles, the appearance of "shiny" skin, and mild to moderate edema. Blanching is observed in first -degree burns, and white, waxy skin is seen in third - and fourth -degree burns.
thickness burn. A nurse is planning care for a patient with a 30% body surface area burn injury. Which statement by the nurse regarding the nutritional status of this patient is true? 1 "Maintaining a hypermetabolic state reduces the patient's risk for infection." 2 "Decreased protein intake will decrease the chance of renal complications." 3 "Controlling the temperature of the environment reduces caloric requirements." 4 "A hypermetabolic state results in poor healing and increased protein and lipid needs." ✅4 "A hypermetabolic state results in poor healing and increased protein and lipid needs." 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 bu rn patient should be increased to promote wound healing. Renal function is monitored for complications, which is low risk with burns, because the need for protein is increased. A hypermetabolic state is not desired and is a complication of a burn injury. C ontrolling the temperature of the environment has no effect on caloric requirements. A burn patient with moist, red, shiny vesicles and blister formation reports severe pain when the site is exposed to air. Which type of burn would the nurse document in the patient's medical record? 1 First -degree burn 2 Third -degree burn 3 Fourth -degree burn 4 Second -degree burn ✅4 Second -degree burn 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 vesicle s or blisters. Third - and fourth -degree burns are characterized by dry, waxy, leathery skin that is insensitive to pain. Which manifestations would the nurse expect when admitting a patient with a full thickness thermal burn? 1 Severe pain, blisters, and blanching with pressure 2 Pain, minimal edema, and blanching with pressure 3 Redness, evidence of inhalation injury, and charred skin 4 No pain, waxy white skin, and no blanching with pressure ✅4 No pain, waxy white skin, and no blanching with pressure 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 -
thickness (deep, second -degree) burns. Pain, minimal edema, blanching, and redness occur with partial -thickness (superficial, first -degree) burns When assessing a patient with a second -degree burn, which clinical manifestations would the nurse anticipate? Select all that apply. 1 Blanching 2 Severe pain 3 White, waxy skin 4 Red, shiny vesicles 5 Mild to moderate edema ✅2 Severe pain 4 Red, shiny vesicles 5 Mild to moderate edema Clinical manifestations of second -degree burns include severe pain, the appearance of fluid-filled vesicles, the appearance of "shiny" skin, and mild to moderate edema. Blanching is observed in first -degree burns, and white, waxy skin is seen in third - and fourth -degree burns.
