Redness and swelling with fluid-filled vesicles noted on right arm.
This describes a partial-thickness burn. Only part of the skin is damaged or destroyed. Large, thick-walled blisters develop, and the underlying tissue is deep red and appears wet and shiny. The damaged skin is painful with increased sensitivity to heat. Healing occurs by evolution of undamaged basal cells and takes about 21 to 22 days.
Charred, waxy, white appearance of skin on the left leg. (Correct Answer)
This describes a full-thickness burn. All the skin is destroyed and the muscle and bone may be involved. The substance that remains is called eschar and is dry to the touch. Full-thickness burns do not heal spontaneously and require grafting. All functions of the skin are lost.
Reddened blotchy painful areas noted on the trunk.
This describes a superficial burn. The skin appears pink and has increased sensitivity to heat. Healing occurs without treatment.
Blistering and blanching of the skin noted on the back.
This describes a partial-thickness burn.
Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a Priority Question.
Priority questions use words such as most, best, first, immediate, etc.
STEP 1: Can you identify the topic of the question?
- Most concerning finding for burns.
STEP 2: Are the answer choices assessment or implementation?
Assessment vs. Implementation
- Redness and swelling with fluid-filled vesicles noted on right arm. Assessment
- Charred, waxy, white appearance of skin on the left leg. Assessment
- Reddened blotchy painful areas noted on the trunk. Assessment
- Blistering and blanching of the skin noted on the back. Assessment
Because a mix of assessment and implementation answer choices does not exist, answer choices cannot be eliminated at this step. Move to Step 3.
STEP 3: Apply Maslow: Are the answer choices physical or psychosocial?
Maslow
- Redness and swelling with fluid-filled vesicles noted on right arm. Physical
- Charred, waxy, white appearance of skin on the left leg. Physical
- Reddened blotchy painful areas noted on the trunk. Physical
- Blistering and blanching of the skin noted on the back. Physical
Because a mix of physical and psychosocial answers does not exist, answer choices cannot be eliminated at this step. Move to Step 4.
STEP 4:Are the answer choices related to ABCs?
ABCs
- Redness and swelling with fluid-filled vesicles noted on right arm. N/A
- Charred, waxy, white appearance of skin on the left leg. N/A
- Reddened blotchy painful areas noted on the trunk. N/A
- Blistering and blanching of the skin noted on the back. N/A
Because a mix of ABC and non-ABC answer choices does not exist, answer choices cannot be eliminated at this step. Move to Step 5.
STEP 5: What is the outcome of each of the remaining answer choices?
Evaluate the outcome(s)
- Redness and swelling with fluid-filled vesicles noted on right arm. Describes a second-degree burn. Eliminate.
- Charred, waxy, white appearance of skin on the left leg. Describes a third-degree burn.
- Reddened blotchy painful areas noted on the trunk.Describes a first-degree burn. Eliminate.
- Blistering and blanching of the skin noted on the back. Describes a second-degree burn. Eliminate.
Select the best choice
Is #3 the correct answer? Yes, #3 describes the worst burn, a third degree burn. This is the most concerning finding.
Does #3 make sense? Yes, a third-degree burn is worse than a first- or second-degree burn and may require surgical intervention for healing.
