A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?
Partial-thickness skin loss.
Necrotic subcutaneous tissue.
Blood-filled blisters.
Exposed bone.
The Correct Answer is B
The correct answer is choice B. Necrotic subcutaneous tissue.
Choice A rationale:
Partial-thickness skin loss (Choice A) is characteristic of a stage II pressure ulcer, not a stage III ulcer. A stage II pressure ulcer involves the loss of the epidermis and possibly the dermis, resulting in a shallow open ulcer with a red-pink wound bed.
Choice B rationale:
Necrotic subcutaneous tissue is a manifestation of a stage III pressure ulcer. A stage III ulcer involves full-thickness skin loss where subcutaneous fat may be visible, but exposed bone or muscle is not yet present. Necrotic tissue in the wound bed indicates a more advanced level of tissue damage and the need for appropriate wound care to promote healing.
Choice C rationale:
Blood-filled blisters (Choice C) are not specific to pressure ulcers and are more commonly associated with friction or shear forces. These blisters are not indicative of a stage III pressure ulcer, which involves visible full-thickness tissue loss.
Choice D rationale:
Exposed bone (Choice D) is a characteristic of a stage IV pressure ulcer, not a stage III ulcer. A stage IV ulcer involves extensive tissue loss with exposure of muscle, tendon, or bone. This represents a severe level of tissue damage and requires intensive wound care and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The left fifth intercostal space at the midclavicular line is the location for palpating the apical pulse, not the pulmonic area. This area is used to assess the heart's apex, particularly for detecting the point of maximal impulse (PMI).
B. The left fifth intercostal space is also associated with the apical pulse, but it lacks the specificity of the midclavicular line, making it less precise for identifying the pulmonic area.
C. The left second intercostal space is the correct location for palpating the pulmonic area. This area is where the pulmonic valve is best auscultated and palpated, allowing for the detection of any abnormal pulsations or sounds related to the pulmonary artery.
D. The right second intercostal space is the location for palpating the aortic area, not the pulmonic area. This site is used to assess the aortic valve and any related abnormalities.
Correct Answer is D
Explanation
Choice A rationale:
Hypotension is not an expected manifestation of hypoxemia during an asthma attack. Hypotension refers to abnormally low blood pressure. During an asthma attack, the body's response to hypoxemia is more likely to involve increased heart rate (tachycardia) as the heart attempts to compensate for decreased oxygen levels.
Choice B rationale:
Dysphagia is not directly related to hypoxemia during an asthma attack. Dysphagia refers to difficulty swallowing, which is not a typical respiratory manifestation. Hypoxemia in asthma is more likely to lead to symptoms such as shortness of breath, wheezing, and increased work of breathing.
Choice C rationale:
Peripheral edema is not a typical manifestation of hypoxemia during an asthma attack. Peripheral edema, or swelling in the extremities, can occur in conditions like heart failure but is not directly related to the airway constriction and reduced oxygen exchange seen in asthma attacks.
Choice D rationale:
Agitation is the correct choice. Hypoxemia, which occurs when there is a decrease in the oxygen levels in the blood, can lead to inadequate oxygen supply to the brain. This can result in neurological symptoms such as agitation, restlessness, confusion, and even loss of consciousness. Agitation is a manifestation of the body's attempt to cope with the lack of oxygen.
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