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 C
Explanation
Correct Answer is A
Explanation
Choice A rationale:
The nurse is demonstrating the concept of disease prevention during a blood pressure screening for a client with a family history of hypertension. Disease prevention involves actions taken to reduce the risk of developing a disease or condition. In this case, the nurse is actively screening for hypertension, a condition that the client may be at risk for due to their family history. By identifying elevated blood pressure early, the nurse can help prevent the progression of hypertension and its associated complications.
Choice B rationale:
Holistic health is a comprehensive approach to healthcare that considers the physical, emotional, social, and spiritual aspects of an individual. While holistic health is an essential aspect of nursing care, the scenario described in the question focuses on a specific action related to blood pressure screening, which is better categorized as disease prevention.
Choice C rationale:
Health promotion involves activities that aim to enhance a person's well-being and quality of life, such as encouraging healthy behaviors and lifestyle choices. While blood pressure screening can be a part of health promotion, the primary goal in the scenario is to identify and prevent hypertension, which aligns more with disease prevention.
Choice D rationale:
Health education refers to the process of providing information and education to individuals to help them make informed decisions about their health. While health education may be a part of the overall nursing care provided to the client, the primary action in the scenario is to perform a blood pressure screening, which is a proactive measure to prevent disease, rather than solely focused on educating the client.
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