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 adipose tissue.
Intact skin with localized erythema.
Full-thickness skin loss with visible bone.
Partial-thickness skin loss with red tissue in the wound bed.
The Correct Answer is B
Choice A rationale:
Full-thickness skin loss with visible adipose tissue is not indicative of a stage 1 pressure injury. A stage 1 pressure injury involves intact skin with localized erythema. Full-thickness skin loss with visible adipose tissue is more characteristic of a stage 2 or higher pressure injury.
Choice B rationale:
Intact skin with localized erythema is the hallmark of a stage 1 pressure injury. In this stage, the skin is still intact, but there is non-blanchable erythema (redness) that indicates tissue damage. There is no full-thickness skin loss, and the underlying structures are not visible.
Choice C rationale:
Full-thickness skin loss with visible bone is not characteristic of a stage 1 pressure injury. This description is more in line with a stage 4 pressure injury, where there is extensive tissue loss, and bone or other underlying structures are visible.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed is not indicative of a stage 1 pressure injury. This description is more typical of a stage 2 pressure injury, where there is partial-thickness skin loss, but the wound bed may contain pink or red tissue without visible adipose tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Prolonged grief is characterized by an extended period of mourning and difficulty in accepting the loss. This type of grief is often associated with intense emotional pain and can last for an extended period, beyond what is considered a normal grieving process. In this scenario, the client's inability to accept the loss of their partner after 3 years is indicative of prolonged grief.
Choice B rationale:
Uncomplicated grief refers to a normal grieving process that follows a loss. It typically involves feelings of sadness, anger, and sorrow, but the individual can eventually accept the loss and continue with their life. The client in the scenario is experiencing prolonged and complicated grief, which does not fit the definition of uncomplicated grief.
Choice C rationale:
Anticipatory grief occurs when individuals start grieving before the actual loss takes place, often seen in situations where a loved one has a terminal illness, and the family begins to mourn the eventual loss. The client in the scenario is not experiencing anticipatory grief, as the loss has already occurred.
Choice D rationale:
Disenfranchised grief refers to grief that is not openly acknowledged or socially supported. It occurs when an individual's loss is not recognized or validated by others, such as in the case of the loss of a same-sex partner, a pet, or a non-traditional relationship. In this scenario, the client's grief is not disenfranchised; it is prolonged and complicated.
Correct Answer is C
Explanation
Choice A rationale:
Peripheral vascular disease does not directly place the client at a higher risk for an incisional hematoma. While it is a vascular condition, the use of anticoagulant medications is a more significant risk factor for bleeding complications.
Choice B rationale:
Urinary incontinence is not directly related to an increased risk of incisional hematoma. Incontinence is a separate issue and does not influence surgical outcomes in the context of hematoma formation.
Choice C rationale:
Taking anticoagulant medications is a significant risk factor for incisional hematoma. Anticoagulants reduce the blood's ability to clot, which can lead to excessive bleeding at the surgical site and the formation of hematomas.
Choice D rationale:
Being underweight is not a primary risk factor for incisional hematoma. While poor nutrition and overall health can influence wound healing, anticoagulant use is a more direct concern for hematoma formation in surgical patients.
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