A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?
Thick, dry, and dark area on bilateral heels.
Broken skin without evidence of undermining.
Defined area of persistent redness over bone.
Superficial sacral ulcer with defined margins.
The Correct Answer is C
Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.
Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.
Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.
Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Children's aspirin is not recommended due to the risk of Reye's syndrome and is not typically used for post-vaccination care.
Choice B reason: While fever can occur after vaccination, not all fevers are serious and can often be managed at home unless they are high or persistent.
Choice C reason: Keeping the child home from daycare is not necessary unless the child is feeling unwell or has a fever.
Choice D reason: Applying a cool pack to the injection site is a common recommendation to reduce discomfort and swelling after vaccinations.
Correct Answer is ["A","B","D","E","F","G"]
Explanation
Choice A Reason: Allowing for menu deviations can help accommodate the patient’s preferences and encourage eating, which is crucial for recovery from emaciation.
Choice B Reason: Setting precise mealtimes can provide structure and consistency, which may help the patient establish regular eating habits.
Choice C Reason: Encouraging exercise is not appropriate at this stage due to the patient’s bradycardia and low BMI, which indicate a high risk for physical complications.
Choice D Reason: Monitoring trips to the restroom is important to prevent purging behaviors, which can be a concern in patients with eating disorders.
Choice E Reason: Providing family education on the condition is essential to ensure that the family understands the patient’s needs and how to support her recovery.
Choice F Reason: Weighing the patient twice weekly can help monitor her progress and adjust the treatment plan as needed.
Choice G Reason: Acknowledging feelings of anxiety is important for addressing the psychological aspects of the patient’s condition and promoting a supportive environment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
