E2 Class Questions

Question 1

A patient with Parkinson’s disease is being treated with carbidopa-levodopa (Sinemet). The patient asks the nurse why he needs both agents. The nurse responds,

a. “The two medicines together are doubly effective.”
b. “This combination has fewer side effects.”
c. “You’ll tolerate this better than a single-agent medication.”
d. “The carbidopa helps the levodopa reach the brain.”

Answer 1

D. The carbidopa helps the levodopa reach the brain

Because of the side effects of levodopa and the fact that so much levodopa is metabolized before reaching the brain, an alternative drug, carbidopa, was developed to inhibit the enzyme dopa decarboxylase. By inhibiting the enzyme in the peripheral nervous system, levodopa reaches the brain. The carbidopa is combined with levodopa in a ratio of 1 part carbidopa to 10 parts levodopa

Question 2

Which comment to the nurse indicates more teaching is needed for a patient taking carbidopa/levodopa?

a. “I know I need to take this drug once a day.”
b. “I know I shouldn’t stop taking this drug abruptly.”
c. “I understand my urine may become dark and discolored.”
d. “I know it may take a few weeks or months to control my symptoms.”

Answer 2

Answer: A “I know I need to take this drug once a day.”

Rationale: A statement from the patient such as “I know I need to take this drug once a day” indicates that more teaching is needed because carbidopa/levodopa has a short half-life and must be taken 3 or 4 times per day. The other answers are true.
NOTE: patients may start on a once-a-day dosing, but the frequency will increase up to 8 doses/day

Question 3

Nursing interventions or patient education for Anti-Parkinson drugs

Answer 3

Nursing interventions:
Monitor for orthostatic hypotension
Administer drug with low-protein foods
High-protein foods interfere with drug transport to CNS
Taking with food can help reduce n/v
Monitor for signs of psychosis
Hallucinations, vivid dreams, paranoia
Do not abruptly discontinue
Warn of harmless brown discoloration of urine and sweat
Assess symptom status and “on-off” phenomenon
Monitor blood cell counts, liver and kidney function

Question 4

All of the following are side effect/adverse effect of carbidopa/levodopa, except?

a. Postural hypotension
b. Decreased libido
c. Cardiac dysrhythmias
d. Dyskinesias

Answer 4

B. Decreased libido

Question 5

Side effects/adverse reactions to Carbidopa/levodopa

Answer 5

Carbidopa-levadopa (Sinemet) Side effects:
Fatigue, insomnia
Dry mouth
Blurred vision
Orthostatic hypotension
Palpitations, dysrhythmias
Urinary retention
Nausea, vomiting
Dyskinesia, psychosis, severe depression
Hemolytic anemia, thrombocytopenia

Question 6

Before administering carbidopa-levodopa (Sinemet) for the treatment of parkinsonism, it is most important for the nurse to assess the patient for a history of

a. pulmonary disease.
b. diabetes mellitus.
c. allergy to penicillin.
d. narrow-angle glaucoma.

Answer 6

Answer: D narrow-angle glaucoma

Rationale: Contraindications to therapy include narrow-angle glaucoma as dilating pupils increase pressure
Other contraindications: severe cardiac, renal, hepatic disease; and suspicious skin lesions (activates malignant melanoma).

Question 7

Common side effects of anticholinergics in body systems (CNS, eyes, GI, Urinary, salivary glands)

Answer 7

CNS - confusion
Eyes – NOT to use with glaucoma (pupils dilate), blurry vision
GI – sluggish…constipation
Urinary – relaxed tone…retention
Salivary glands – dry mouth

Question 8

A patient has been diagnosed with Alzheimer’s disease. The patient’s daughter asks the nurse what the cause of Alzheimer’s disease is. The best response by the nurse is “The cause of Alzheimer’s disease is

a. a virus
b. a cancer
c. unknown
d. normal aging

Answer 8

C. unknown
The cause of alzheimers is currently unknown

Question 9

The nurse should teach the patient’s family to administer the medication rivastigmine (Exelon)

a. without food.
b with meals.
c. at 3:00 am and 3:00 pm.
d. when the patient is acting most confused.

Answer 9

B. Twice a day with food

Highest incidence of GI effects of any other drugs in this class

Question 10

The patient’s daughter is with the nurse and is concerned about side effects of rivastigmine (Exelon).
What are the major side effects and what precautions or interventions can be done?

Answer 10

Rivastigmine (Exelon) Side effects:
Anorexia, nausea, vomiting, diarrhea, constipation, abdominal pain, dizziness, depression, peripheral edema
Has the highest incidence of GI effects of any other drugs in this class!
Adverse reactions: bradycardia, orthostatic hypotension, myocardial infarction, bronchoconstriction
Safety: prevent falls/fractures

Question 11

The patient and her family want to know how the medication works. The nurse’s response would include which information? (Be sure to use terms that non-health care individuals can understand.)

Answer 11

The nurse will tell the patient that the medication will increase the level of a chemical in the brain, acetylcholine, allowing for better communication between cells involved in maintaining memory.

Rationale: Rivastigmine is an acetylcholinesterase inhibitor, which increases the amount of ACh at cholinergic synapses. AChE inhibitor
Used in patients with mild to moderate Alzheimer’s disease
Increases the amount of ACh at the cholinergic synapses
Potentially slows the disease process

Question 12

The nurse is assessing an 8-year-old male patient who has a history of attention deficit hyperactivity disorder. The patient’s father notes that even though the child has been taking methylphenidate for 1 week, the child’s teacher still reports fidgeting and inattentiveness in class. The nurse notes that the patient is staring at his shoes and won’t look at her.

The patient’s father is concerned that the medication isn’t working. How will the nurse respond?

Answer 12

The nurse will explain that often the medication dosage is titrated to meet the individual needs of each patient. The nurse will let the father know that his concerns will be shared with the prescriber

Rationale: The dosage is often increased by 5 mg weekly until a desired effect or a maximum dose is reached.

Question 13

ADHD peds case: The patient’s father wants to know the signs he should be looking for that the medication is having a therapeutic effect. What teaching will the nurse provide?

Answer 13

The nurse will advise the patient’s father that he should look for an improved attention span and/or improved ability to focus in the child. The father may also look for other signs, such as improving grades or fewer calls from the teacher.

Rationale: The medication is given to improve attention span and cognitive performance. decrease impulsiveness, hyperactivity, and restlessness

Question 14

How does methylphenidate interact with caffeine?
Blood pressure medications?

Answer 14

How does methylphenidate interact with caffeine?
Potentiates amphetamine-like effect, may be fatal!

Blood pressure medications?
May decrease effect

Additionally, when taken with MAOIs - Risk of hypertensive crisis

Question 15

Common Side Effects/Adverse reactions of methylphenidate

Answer 15

Tachycardia, palpitations, dizziness, hypertension
Sleeplessness, restlessness, nervousness, tremors, irritability
Increased hyperactivity
Anorexia, dry mouth, vomiting, diarrhea, weight loss
Thrombocytopenia

Question 16

Important nursing interventions and patient education on methylphenidate?

Answer 16

Nursing interventions and patient education
Give with breakfast and lunch.
Report irregular heartbeat.
Record height, weight, and growth of children
Avoid alcohol, caffeine.
Use sugarless gum to relieve dry mouth.
Counseling must also be used.

Question 17

What would indicate to the nurse that the child taking methylphenidate requires more teaching?

a. The child is seen drinking a cola product.
b. The child checks his weight twice a week.
c. The child takes the drug 45 minutes before a meal.
d. The child takes the drug before breakfast and lunch.

Answer 17

Answer: A. the child is seen drinking cola

Rationale: The nurse should teach the child to avoid caffeine because of its potentiation of methylphenidate.
The child should be checked twice a week for weight loss.
The drug should be taken before breakfast and lunch and not within 6 hours of sleeping.

Question 18

Methylphenidate (Ritalin) should not be taken by patients with a history of which condition?

a. Renal failure
b. Cataracts
c. Hypothyroidism
d. Coronary artery disease

Answer 18

D. CAD
Rationale: Methylphenidate (Ritalin) is contraindicated in patients who have a history of heart disease, hypertension, hyperthyroidism, parkinsonism, or glaucoma.

Question 19

When providing teaching to a group of parents regarding attention deficit/ hyperactivity disorder (ADHD), which information will the nurse include?

a. Children with ADHD have low intelligence.
b. Children with ADHD have an infection in their spinal fluid.
c. EEG results are typically normal in children with ADHD.
d. Learning disabilities are often present in the child who has ADHD.

Answer 19

D. learning disabilities often present in children with ADHD

Rationale: Intelligence is usually not affected by ADHD. The CSF of children with ADHD is not affected. Children with ADHD often have abnormal EEG studies. Children with ADHD often have learning disabilities.

Question 20

Now that you know something about Doxapram, what is the difference between it and Narcan? Why is Narcan the first choice for opioid overdose?

Answer 20

Doxapram is a respiratory stimulant
Narcan is an antidote – blocks effect of opioid

Question 21

A patient has been ordered a transdermal patch of methylphenidate (Ritalin). The nurse teaches the family to leave the patch on for how long?

a. 2 hours
b. 9 hours
c. 12 hours
d. 24 hours

Answer 21

B. 9 hours

Question 22

Action of acetylcholinesterase inhibitor/cholinesterase inhibitors in relation to myasthenia gravis

Answer 22

Actions: Binds cholinesterase, not allowing the breakdown of ACh; transmission of neuromuscular impulses is allowed
Results in improved muscle strength and function

Question 23

Acetylcholinesterase inhibitor/cholinesterase inhibitors side effects

Answer 23

AChE Inhibitors Side effects:
GI disturbances (nausea, vomiting, diarrhea, abdominal cramps)
Increased salivation
Tearing
Sweating
Miosis (constricted pupil of the eye)
Blurred vision
Bradycardia
Hypotension
Bronchial constriction
Urinary urgency
Think cholinergic effects!

Question 24

Describe neostigmine (Prostigmin), physostigmine (Antilirium) & pyridostigmine (Mestinon) as used in treatment of MG.

Answer 24

Cholinesterase inhibitors - inhibit the action of the enzyme, result: more acetylcholine is available to activate the cholinergic receptors and promote muscle contraction.
Neostigmine (Prostigmin): short-acting, frequent dosing required
Pyridostigmine (Mestinon): intermediate-acting
Also used for tx of nerve gas exposure
Muscle relaxant antagonist
Physostigmine (Antilirium): crosses blood-brain barrier, given via IM or IV

Question 25

Acetylcholinesterase inhibitor/cholinesterase inhibitors - Nursing interventions and education

Answer 25

Nursing interventions:
Administer doses on time.
Take drug before meals if possible.
Monitor drug effectiveness.
Muscle strength
Salivation
Ability to swallow
Have antidote available for cholinergic crisis.
Atropine
Encourage patient to wear medical identification.

Question 26

A patient with myasthenia gravis comes to the emergency department in respiratory distress. He has been diagnosed with myasthenic crisis. The nurse anticipates administration of which drug?

a. Diazepam (Valium)
b. Baclofen (Lioresal)
c. Edrophonium (Tensilon)
d. Neostigmine (Prostigmin)

Answer 26

D. Neostigmine (Prostigmin)

Myasthenic Crisis – severe muscle weakness, may involve respiratory muscles
Causes: underdosing of AChE inhibitors, stress, illness, pregnancy, aminoglycoside, fluoroquinolones, CCBs, phenytoin, psychotropics

Rationale: Neostigmine (Prostigmin) is a short-acting acetylcholinesterase inhibitor which can relieve myasthenic crisis.
diazepam is an anxiolytic, and baclofen is a muscle relaxant.

Question 27

The patient is prescribed pyridostigmine (Mestinon). To avoid development of myasthenic crisis in the future, the nurse should include which information in the patient teaching?

a. Take muscle relaxants for cramps.
b. Take medication with meals.
c. Medication should be taken at the same time everyday.
d. Medication should be taken at the time of day when you feel the weakest.

Answer 27

C. Meds should be taken at the same time everyday

Rationale: Patient’s symptoms of muscle weakness and difficulty breathing and swallowing caused by MG will be eliminated or reduced in 2 to 3 days. Patients taking pyridostigmine (Mestinon) should avoid atropine, atropine-like drugs, and muscle relaxants. Inform the patient to take drug before meals for best drug absorption. The medication should be taken at the same time every day.

Question 28

The patient is readmitted to the emergency department a few weeks later and is diagnosed with cholinergic crisis. The nurse anticipates administration of

a. atropine sulfate.
b. baclofen (Lioresal).
c. edrophonium (Tensilon).
d. neostigmine (Prostigmin).

Answer 28

A. atropine sulfate

Cholinergic Crisis – severe muscle weakness, may involve respiratory muscles, N/V, diaphoresis, bradycardia, excess salivation, miosis
Causes: overdose of AChE inhibitors, overstimulates parasympathetic nervous system

Rationale: Atropine sulfate is an antidote for cholinergic crisis.

Question 29

When a patient with myasthenia gravis comes to the emergency department in respiratory distress, the nurse anticipates administration of which drug to determine if the patient is in myasthenic crisis or cholinergic crisis?

a. Diazepam (Valium)
b. Baclofen (Lioresal)
c. Edrophonium (Tensilon)
d. Neostigmine (Prostigmin)

Answer 29

C. Edrophonium (Tensilon) if med relieves sysmtoms, myastenic crisis is the diagnosis. If there is no relief then it is a cholinergic crisis (give atrophine)

Rationale: Edrophonium (Tensilon) is ultrashort-acting and most commonly used to differentiate between myasthenic crisis and cholinergic crisis. Edrophnium is not used as frequently when newer diagnostic tools are available.
Neostigmine is a short-acting AChE inhibitor; diazepam is an anxiolytic, and baclofen is a muscle relaxant.

Question 30

A student nurse asks the ED nurse which symptom is most likely to differentiate myasthenic crisis from cholinergic crisis. The ED nurse should say that even though the symptoms of the two conditions are similar, which is most likely to occur with cholinergic crisis?

a Drooling
b Muscle weakness
c Dyspnea
d Dysphagia

Answer 30

A. Drooling

Rationale: Overdosing and underdosing of AChE inhibitors have similar symptoms: muscle weakness, dyspnea (difficulty breathing), and dysphagia (difficulty swallowing). Additional symptoms that may be present with overdosing are bradycardia, abdominal cramping, N/V, sweating, pupil constriction – think stimulation of parasympathetic nervous system!

Question 31

A patient is being treated with interferon beta-1a [Avonex] for MS. The patient calls the clinic to report headache, fever, chills, and muscle aches after administering a dose. What will the nurse recommend?
a. Coming to the clinic for evaluation for leukoencephalopathy
b. Asking the provider to order a complete blood count (CBC)
c. Acetaminophen or ibuprofen
d. Discontinuing the drug immediately

Answer 31

C. Acetaminophen or ibuprofen

A patient is being treated with interferon beta-1a [Avonex] for MS. The patient calls the clinic to report headache, fever, chills, and muscle aches after administering a dose. What will the nurse recommend?
Coming to the clinic for evaluation for leukoencephalopathy
Asking the provider to order a complete blood count (CBC)
Acetaminophen or ibuprofen
Discontinuing the drug immediately

Question 32

WHAT Patient teaching will you provide for CNS depressants?

Answer 32

May cause drowsiness
Don’t take with ETOH
Don’t use while driving, using heavy equipment

Question 33

The nurse identifies which patient as being least likely to experience adverse effects of cyclobenzaprine (Flexaril) therapy? The patient

a. who is taking an MAOI.
b. with a history of narrow-angle glaucoma.
c. who has a history of myasthenia gravis.
d. who is prescribed an oral antidiabetic agent.

Answer 33

D. Prescribed an oral antidiabetic

Cyclobenzaprine is contraindicated if patient has cardiovascular disorders, hyperthyroidism, hepatic impairment, or taking concurrent MAOIs. The nurse should note if there is a history of narrow-angle glaucoma or MG. Cyclobenzaprine (Flexeril) is contraindicated with these health problems.

Question 34

A patient with myasthenia gravis is prescribed neostigmine bromide (Prostigmin). The nurse identifies that the medication has been effective when the patient experiences?

a. Increased muscle strength
b. Decrease in sweating and salivation
c. Changes in vital signs to within normal limits
d. Decrease in generalized pain

Answer 34

A. Increased muscle strength

Improved muscle strength indicates that neostigmine bromide (Prostigmin) therapy is exerting a therapeutic effect.

Question 35

A child with cerebral palsy is ordered to receive baclofen (Lioresal). The nurse is aware that this medication is prescribed to

a. induce sleep and rest.
b. increase appetite.
c. reduce muscle spasticity.
d. increase bowel function.

Answer 35

C. Reduce muscle spasticity

Rationale: Muscle relaxants are used to decrease a patient’s muscular pain and spasticity.

Question 36

The nurse teaches a patient that a “drug holiday” is recommended with which herbal preparation?

a. St. John’s wort
b. Echinacea
c. Ginkgo biloba
d. Valerian

Answer 36

B. Echinacea

Rationale: German Commission E recommends use of echinacea for up to 8 weeks if the dose is low. Others recommend limiting use to 2 weeks and taking a week’s drug holiday from this product before continuing therapy.
May cause problems with natural GI flora, as ABX can;
risk for C. Difficile

Question 37

Which neurotransmitter causes dilation of the pupils?

Norepinephrine
Acetylcholine

Why is this important for patients with glaucoma?

Answer 37

Norepinephrine
Rationale: Dilation of pupils allows flexibility of the iris, blocking flow of aqueous humor, increasing IOP, affects Narrow Angle Glaucoma

Question 38

MH, a 70-year-old woman with POAG, is prescribed one drop of latanoprost (Xalatan) 0.005% ophthalmic solution each evening and one drop of timolol (Timoptic) 0.25% ophthalmic solution each morning and evening.
What is the purpose of giving two different medications to manage MH’s glaucoma?

Answer 38

Latanoprost is a prostaglandin analogue that decreases intraocular pressure (IOP) by increasing outflow of aqueous humor.
Timolol is a beta-adrenergic blocker that decreases IOP by decreasing production of aqueous humor.
Together, they have additive effects that may be necessary if either is insufficient in decreasing IOP alone.

Question 39

What special concerns related to medication timing are important for MH to consider when administering these two medications?

Answer 39

M.H. needs to wait 5 minutes after administration of the first drug before using the second drug. This will allow adequate absorption of the first drug and prevent overflow of the second drug

Question 40

What if both eye drops and eye ointment are prescribed? Should one be administered first?

Answer 40

Instruct patient to put eye drops in first
Also remember that ointments can blur vision temporarily

Question 41

Although systemic absorption of ophthalmic beta-adrenergic blockers is usually small, it may potentially create problems for patient with certain conditions. Which conditions create a risk, and how will the nurse monitor for complications?

Answer 41

Some conditions are worsened by beta-adrenergic blockers. These include respiratory diseases such as asthma and chronic obstructive pulmonary disease and cardiac conditions such as AV heart block, bradycardia, or heart failure.
Monitor for problems by including questions about respiratory or cardiac issues and by assessing respiratory and cardiac status at each appointment.

Question 42

When administering a beta-adrenergic blocker, what technique can the nurse use to help prevent systemic side effects such as bradycardia?

Answer 42

Apply pressure to the lacrimal duct for 1-2 minutes when instilling drops prevents systemic absorption.

Question 43

What are some other side effects (to the eyes) of beta-adrenergic blockers?

Answer 43

Eye discomfort
Miosis – causes difficulty with night vision
Miosis, because eye cannot fully dilate in darkness, night vision is affected

Question 44

After a few months on these medications, MH notices changes in the appearance of her eyes. Describe the changes that MH is likely experiencing, and explain which drug is responsible.

Answer 44

M.H. may be experiencing one or several of the following changes due to side effects of the latanoprost (Xalatan) . Prostaglandin analogs can cause increased pigmentation of the iris as well as the skin around the eye. These drugs also cause an increase in the number, length, and thickness of eyelashes. Lashes also typically darken.
Additional side effects include blurred vision, redness of the conjunctiva, and itching or stinging of the eye

Question 45

What physical exam assessments will you do for a patient with eye symptoms?

Answer 45

What physical exam assessments will you do for a patient with eye symptoms?

Question 46

A 3 year old female patient, weighing 42 lbs with AOM has the following order: Amoxicillin 45 mg/Kg/day PO in equally divided doses every 12 hours x 7 days

Available: Amoxicillin 250 mg/5 mL or 400 mg/5 mL

What dose will you give? Why?

Answer 46

mL = 5mL/250mg x 45 mg/Kg x Kg/2.2lb x 42lb = 17.18mL per day or 8.59mL per dose

mL = 5mL/400mg x 45 mg/Kg x Kg/2.2lb x 42lb = 10.73 mL per day or 5.36mL per dose
Give the smaller volume (more concentrated dose); child is more likely to get entire dose

Question 47

The nurse is showing the parent of a 2-year-old child how to administer eardrops. Which are correct statements? (Select all that apply.)

A. Pull down and back on auricle.
B. Pull up and back on the auricle.
C. Position child’s head with affected ear up.
D. Position child’s head with affected ear down.
E. Warm the eardrop in the microwave prior to administration.

Answer 47

A, C
The child should sit up with head tilted slightly toward unaffected side. This position straightens the external ear canal for better visualization. The nurse or parent should pull down and back on the auricle for a child younger than 3 years of age.

Question 48

Pilocarpine has which action on the eye?

a. Miosis
b. Mydriasis
c. Ciliary muscle paralysis
d. Pupillary dilation

Answer 48

Answer: A Miosis
Pilocarpine, a cholinergic agent, produces miosis (constriction of the pupil) and decreases IOP.

Question 49

A child is treated four times during the summer for external ear infections, or “swimmer’s ear.” The nurse teaches the family to prevent these infections by

a. refraining from any submersion in water.
b. continuing antibiotic therapy through the summer season.
c. taking high-dose vitamin C.
d. using custom-fitted ear plugs.

Answer 49

d. using custom-fitted ear plugs

If the patient is prone to OE after swimming or showers, the nurse should advise the patient to keep water out of ears by using custom-fitted ear plugs and to use a portable hair dryer to facilitate drying. If water enters the ear, the patient can tilt the ear downward to allow water to drain out or pull the ear in different directions to enhance water drainage.

Question 50

S.T. is a 23-year-old female patient who is being treated for plaque psoriasis. She is taking both oral and topical medications. The patient voices concerns that she can’t go out in the sun and that she won’t be able to have children because of these medications.

What education will the nurse provide about sunlight?

Answer 50

In moderation, the UV radiation (sunlight) will be useful to the plaque psoriasis.
Some dermatologists use UV radiation as a means of treating psoriasis.

What education would be appropriate regarding pregnancy?

Question 51

What education would be appropriate regarding pregnancy? Regarding plaque psoriasis topical + oral medications

Answer 51

It is very important to help the patient understand that these medications will not stop her from becoming pregnant. What many antipsoriatic drugs do is cause severe birth defects in the baby.
It is very important for the patient to avoid pregnancy while using these medications for psoriasis.

Question 52

There are several topical agents used to treat psoriasis. What patient education might be needed for some of these options? Specifically anthralin, salicylic acid, coal tar, calcipotriene, calcitriol, and tazarotene

Answer 52

Topical med
Glucocorticoids – topical
apply thin layer, may cause thinning of the skin
Use lowest strength that is effective
Do not use on the face (skin atrophy) or intertriginous areas (secondary bacterial infections)
Anthralin (Psoriatec)– topical
May stain clothing, skin, hair
May cause local irriatation, erythema
Coal tar – topical
May stain, cause burning
Some OTC shampoos available
Tazarotene (Tazorac) – topical
Vit A derivative, local irritation where applied
Teratogenic!
Use sunscreen
Calcipotriene (Dovonex), calcitriol (Vectical) – topical
Vit D3 derivative
May cause excess Ca++ Monitor serum & urine Ca! Apply thin layer to affected skin

Question 53

Finasteride (Propecia) is used to treat male pattern baldness. The nurse knows that in higher doses, the drug is used to treat which condition?

a. Benign prostatic hypertrophy
b. Gastroesophageal reflux
c. Migraine headache
d. Impotence

Answer 53

Answer: A Benign prostatic hypertrophy

Finasteride (Propecia, Proscar) is an oral drug used for male baldness. It is available in 1-mg tablets. (A 5-mg tablet is prescribed for benign prostatic hyperplasia.)

Question 54

A patient is ordered to receive isotretinoin (Amnesteem) for acne vulgaris. What is considered priority information in teaching this patient?

a. Good skin hygiene
b. Optimal nutritional practices
c. Contraception or abstinence from sexual intercourse
d. Methods to avoid infection

Answer 54

C Contraception or abstinence from sexual intercourse

Isotretinoin must not be used during pregnancy because of its powerful teratogenicity. For female patients, two effective methods of contraception are required 1 month before, through the duration, and 1 month after terminating isotretinoin treatment.

Question 55

A patient is admitted to the emergency department with a burn that consists of pearly white skin with areas that are charred. The patient is not in pain. The nurse documents the burn as

a. superficial epidermal.
b. partial thickness superficial.
c. deep thickness.
d. full thickness.

Answer 55

Answer: D full thickness
Superficial epidermal burns are red and painful; partial thickness superficial burns are blistering and very painful, and deep thickness burns are mottled and blistering with intense pain.