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 D
Explanation
A. Vitamin B1 (thiamine) is a water-soluble vitamin.
B. Vitamin B12 is a water-soluble vitamin.
C. Vitamin C is a water-soluble vitamin.
D. Vitamin A is a fat-soluble vitamin, along with vitamins D, E, and K. Clients with pancreatitis may have difficulty absorbing fat-soluble vitamins due to impaired pancreatic function.
Correct Answer is D
Explanation
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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