A client is experiencing a full-thickness burn. What should the nurse expect to assess for this burn?
1. Damage has occurred to the epidermis
2. Damage has occurred to the muscle
3. Damage is noted in the dermis
4. The damage has made the skin pink
Answer: 2
1. The epidermis involves the top layer of skin and is a superficial burn.
2. Muscle involvement indicates deep tissue involvement and a full-thickness burn.
3. Damage only as far as the dermis is considered a partial-thickness burn.
4. Pink skin would indicate a superficial burn.
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