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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Physician assistants typically assist with medical diagnoses and treatment plans, not rehabilitation.
B. Physical therapists focus on physical movement and rehabilitation, not typically assisting with activities of daily living such as feeding.
C. Occupational therapists specialize in helping individuals with daily activities, making them the appropriate referral for this client's needs.
D. Social workers typically provide assistance with psychosocial support and community resources, which may be needed but are not as directly related to the client's physical limitations.
Correct Answer is A
Explanation
A. Grilled salmon is high in protein and also provides omega-3 fatty acids, which are beneficial for wound healing.
B. Kidney beans are a good source of protein but not as high as salmon.
C. Raw spinach is nutritious but low in protein.
D. Peanut butter contains protein, but not as much as salmon and may not be as easily digestible for some patients.
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