Patho Patho #82

Question

When assessing a client with full thickness burns, the nurse expects:

Answers

  1. 1. small, fluid filled blisters covering the area that has been burned.
    • Rationale:

      This answer choice is not correct because full thickness burns do not include blisters. Partial thickness burns present with fluid filled blisters.

  2. 2. decreased heart rate and increased blood pressure.
    • Rationale:

      This answer choice is not correct because clients with severe burn injuries present with increased metabolic rates, including an increased heart rate with possible low blood pressure due to fluid volume deficit.

  3. 3. hyperactive bowel sounds with decreased digestion.
    • Rationale:

      This answer choice is not correct because clients with severe burn injuries have increased metabolic rates. The sympathetic nervous system dominates and bowel sounds will be hypoactive or absent due to decreased parasympathetic nervous system activity.

  4. 4. dry, leathery, waxy-white tissue.
    • Rationale:

      This answer is correct because full thickness burns present as dry, leathery, and possibly white, red, or dark brown with a waxy appearance.

Overview

The focus of this question is asking the nurse to identify the appearance associated with a full thickness burn. Full thickness burns are burns that cause damage all the way through the epidermis, dermis, and underlying tissue. Full thickness burns are painless as nerve endings are destroyed. The site of a full thickness burn appears dry, leatheray, and may have a waxy-white appearance.

Explanation

Learning Outcomes

Full thickness burns destroy the first two layers of the skin, the epidermis and dermis, They appear very dry, leathery, and may appear white, red, or dark brown. There are no blisters associated with full thickness burns.

Test Taking Tip

Superficial burns appear as reddened areas. Partial thickness burns will classically present with fluid filled blisters and pain. Full thickness burns are dry, without associated blisters, and painless as nerve endings have been destroyed.

Video Rationale