A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?
Full thickness skin loss with visible bone
Full thickness skin loss with visible adipose tissue.
Partial-thickness skin loss with red tissue in wound bed
Intact skin with localized erythema
The Correct Answer is D
A. Full thickness skin loss with visible bone describes a stage 4 pressure injury.
B. Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury.
C. Partial-thickness skin loss with red tissue in the wound bed describes a stage 2 pressure injury.
D. Intact skin with localized erythema (redness) that does not blanch when pressure is applied is characteristic of a stage 1 pressure injury.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While some clients with chronic pain may develop coping mechanisms, this does not mean that measures for relief are unnecessary. Pain management is still crucial for maintaining quality of life.
B. Opioid-based analgesics can be effective for some individuals with chronic pain, but their effectiveness can vary and they may not always be the best option due to potential side effects and the risk of dependence.
C. Chronic pain can be challenging to assess, but the perception and expression of pain are subjective and can vary greatly among individuals. Constant complaints of pain do not necessarily mean the pain intensity is difficult to assess; rather, it indicates the need for thorough pain evaluation.
D. Chronic pain often does not trigger the same physiological responses as acute pain. Therefore, vital signs such as heart rate, blood pressure, and pulse rate may remain normal even while the client is experiencing pain. This can make it more challenging to assess the presence and intensity of pain solely based on these parameters.
Correct Answer is A
Explanation
A. Watching television until falling asleep can interfere with the ability to fall asleep and stay asleep due to the stimulating effects of screen time and blue light.
B. Having a small snack and taking a bath before bed are good practices that can promote relaxation and help induce sleep.
C. Avoiding naps throughout the day can help improve nighttime sleep quality and maintain a consistent sleep schedule.
D. Going to bed and getting up at the same time each day helps regulate the body's internal clock and improve sleep quality.
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