Question

A male client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse?

Answer 1

The assessment finding that warrants immediate intervention by the nurse is the presence of large blisters over the client's back and chest with serosanguinous fluid. This may indicate a severe sunburn with blistering, which requires immediate attention to prevent complications.

Step-by-step explanation:

The assessment finding that warrants immediate intervention by the nurse is the presence of large blisters over the client's back and chest, with the shirt soaked with serosanguinous fluid. This indicates a severe sunburn with blistering, which can be a sign of a second-degree burn.

Second-degree burns involve damage to the epidermis and dermis layers of the skin. The formation of blisters is a protective response of the body to prevent infection and promote healing. However, if the blisters are large and there is excessive fluid leakage, it may indicate a more severe injury.

In this case, immediate intervention is necessary to prevent further complications and promote proper wound management. The nurse may need to assess the extent of the burn, provide appropriate wound care, administer pain medication, and monitor for signs of infection.