NURS 272 Exam 4 Questions And 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 - answ...
5 Mild to moderate edema - answer✔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?
5 Difficulty in swallowing - answer✔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, bronchioles, 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. - answer✔1 Touch sensation is impaired.
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 are 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." -
answer✔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 burn 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. Controlling 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
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