While changing the dressing on a burned arm the patient complains of feeling cold and having extreme pain. However, the patient asks the nurse to not apply so much pressure when wrapping gauze around the limb. What should these findings indicate to the nurse?

Correct Answer: C

Rationale: The correct answer is C: Encapsulated nerve endings in the arm are intact. This is indicated by the fact that the patient is experiencing extreme pain (associated with free nerve endings) but can still differentiate pressure sensation (associated with encapsulated nerve endings). If all nerves were damaged (Choice A), the patient would not feel any sensation. If free nerve endings were injured (Choice B), the patient would not feel pain. If encapsulated nerve endings were injured (Choice D), the patient would not be able to differentiate pressure sensation.

Correct Answer: D

Rationale: The correct answer is D: Promote the patient's highest possible level of function. The primary goal of a multidisciplinary rehabilitation team caring for a patient who has had an amputation is to help the patient achieve their maximum functional ability and independence. This goal involves various specialists working together to provide comprehensive care tailored to the patient's specific needs. Maximizing efficiency of care (A) is important but not the primary goal. Ensuring holistic healthcare (B) is valuable but not the primary focus. Facilitating adjustment to a new body image (C) is important, but the primary goal is to promote the patient's functional abilities.

Correct Answer: B

Rationale: The correct answer is B: Flush the wound bed with sterile saline. Prior to obtaining a wound culture specimen, flushing the wound bed with sterile saline helps remove debris and contaminants. This step ensures that the specimen collected is not contaminated, providing accurate culture results. Applying clean gloves (A) is important but does not directly impact the quality of the specimen. Cleansing the wound with antimicrobial solution (C) may interfere with the culture results by killing bacteria present. Keeping the wound open to air for several minutes (D) does not contribute to obtaining a clean specimen.

Correct Answer: B

Rationale: The correct answer is B: Serum protein level 7.1 g/dL. This indicates effective teaching as it shows an improvement in the patient's nutritional status. Serum protein levels reflect protein intake and liver function, which are crucial for healing after burns. Weight loss (A) is not indicative of nutritional improvement in this context. Low serum albumin level (C) suggests protein malnutrition, not improvement. Choice D is not a valid option.

Correct Answer: D

Rationale: The correct answer is D: Suspected tissue injury. This classification is appropriate because the skin presentation described does not meet the specific criteria for Stage III or IV ulcers, which involve skin breakdown and tissue damage extending into deeper layers. The term "unstageable" is used when the wound bed is obscured, usually by eschar or slough, making it impossible to determine the depth of tissue damage. In this case, the presence of a blood-filled blister and pain suggests a superficial injury without visible tissue loss, indicating a suspected tissue injury rather than a defined stage of ulcer development. This classification allows for further assessment and monitoring to determine the extent of tissue damage.