A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

Intact skin with localized erythema.

Full-thickness skin loss with visible adipose tissue.

Partial-thickness skin loss with red tissue in wound bed.

Full-thickness skin loss with visible bone.

Answer and Explanation

The Correct Answer is C

A: Intact skin with localized erythema describes a stage 1 pressure injury, where the skin is not broken but shows signs of redness and irritation. This stage does not involve any loss of skin layers.

B: Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury. At this stage, the injury extends through the full thickness of the skin and exposes fat tissue, but not muscle, bone, or tendon.

C: Partial-thickness skin loss with red tissue in the wound bed is indicative of a stage 2 pressure injury. This stage involves damage to the epidermis and dermis, resulting in a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.

D: Full-thickness skin loss with visible bone describes a stage 4 pressure injury. This stage involves extensive destruction, with tissue loss extending to muscle, bone, or supporting structures.

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Correct Answer is A

Explanation

A: The nurse should check the medication order again to ensure that the correct medication is being administered. This response addresses the client’s concern and ensures patient safety.

B: Telling the client that this is the medication their doctor wants them to take does not address the client’s concern about the color difference and may not ensure the correct medication is given.

C: While it is true that the same medication can come in different colors, this response does not verify the accuracy of the medication being administered.

D: Explaining the purpose of the medication is important, but it does not address the immediate concern about the color difference and the need to verify the medication.

A. “I will wear earphones during this test.” B. “A small probe is placed inside my ear.” C. “Small electrodes are placed on my scalp.” D. “A tuning fork is placed on my head.”

Correct Answer is D

Explanation

A: Wearing earphones is not part of the Rinne test. Earphones are used in other types of hearing tests, such as audiometry.

B: A small probe is not used in the Rinne test. Probes are used in other diagnostic procedures, such as tympanometry.

C: Small electrodes are not used in the Rinne test. Electrodes are used in tests like electroencephalography (EEG).

D: A tuning fork is placed on the mastoid bone behind the ear and then near the ear canal during the Rinne test. This test compares air conduction to bone conduction of sound.

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A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

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