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:
"Keep your back straight.”. Maintaining correct posture when transferring clients is essential to prevent injuries to both the nurse and the patient. The correct answer, "Keep your back straight," is crucial in ensuring that the nurse avoids straining their back muscles. When transferring patients, it's essential to use proper body mechanics and keep the spine in a neutral position. This minimizes the risk of back injuries and promotes safe patient handling. Bending or twisting the back can lead to musculoskeletal problems, such as back pain or herniated discs.
Choice B rationale:
"Keep your knees straight.”. Keeping your knees straight is not the correct choice for maintaining correct posture when transferring clients. In fact, it's essential to keep your knees slightly bent when lifting or transferring a patient. This position helps to maintain stability and distribute the weight evenly, reducing the risk of injury.
Choice C rationale:
"Tilt your head toward your chest.”. Tilting the head toward the chest is unrelated to maintaining proper posture during patient transfers. It is important to keep the head in a neutral position while transferring patients, focusing on the back and leg positioning.
Choice D rationale:
"Loosen your abdominal muscles.”. Loosening abdominal muscles is not a recommended practice during patient transfers. Maintaining core strength and stability is essential for proper body mechanics. Relaxing the abdominal muscles can lead to poor posture and decreased stability, increasing the risk of injury.
Correct Answer is B
Explanation
Choice A rationale:
Trust vs. Mistrust is the first stage of Erikson's theory of psychosocial development and typically occurs in infancy. It is characterized by the child's development of trust or mistrust based on the caregiver's reliability and care. This stage is not relevant to an adolescent who is rebelling against caregivers and spending more time with friends.
Choice B rationale:
Identity vs. Role Confusion is the stage of Erikson's theory that corresponds to adolescence. During this stage, adolescents seek to establish a sense of identity and may experiment with different roles and behaviors. They often question who they are and what they want to become. Rebelling against caregivers and seeking independence are common characteristics of this stage.
Choice C rationale:
Integrity vs. Despair is the final stage of Erikson's theory and occurs in late adulthood. It involves reflecting on one's life and coming to terms with the choices made. It is not relevant to the situation of an adolescent client.
Choice D rationale:
Autonomy vs. Shame and Doubt is the stage that typically occurs in early childhood, where children are developing a sense of independence and autonomy. This stage is not relevant to the adolescent client's experience of rebellion and seeking autonomy.
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