A nurse is assessing a client who has a stage 2 pressure injury.
Which of the following findings should the nurse expect?
Full thickness skin loss with visible bone.
Intact skin with localized erythema.
Full thickness skin loss with visible adipose tissue.
Partial-thickness skin loss with red tissue in wound bed.
The Correct Answer is D
Choice A rationale:
Full thickness skin loss with visible bone. This choice does not align with the description of a stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness skin loss, but they do not involve visible bone. This description corresponds to a more severe stage of pressure injury.
Choice B rationale:
Intact skin with localized erythema. This choice describes a normal skin condition with localized redness (erythema) but does not indicate the presence of a pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, which means there is a break in the skin integrity.
Choice C rationale:
Full thickness skin loss with visible adipose tissue. This description is more in line with a stage 3 pressure injury, not a stage 2 injury. In stage 3, there is full-thickness skin loss, and adipose tissue may become visible in the wound bed. However, in stage 2, the skin loss is partial-thickness, and the wound bed typically contains red tissue.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed. This choice is the correct description of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss with the presence of red or pink tissue in the wound bed. It signifies damage to the epidermis and possibly the dermis. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Decreased thickness of tympanic membranes is not a typical physiological change in older adults. Tympanic membranes tend to become thinner and less flexible with age, leading to increased susceptibility to damage, not decreased thickness.
Choice B rationale:
Decreased tinnitus is not a physiological change related to aging. Tinnitus can occur in individuals of all ages and is often associated with various factors such as exposure to loud noises, ear infections, or underlying medical conditions.
Choice C rationale:
Decreased ear wax is not a typical physiological change in older adults. In fact, older adults may experience increased production of earwax, which can lead to hearing problems if not managed appropriately.
Choice D rationale:
Decreased ability to hear high-frequency sounds is a common physiological change in older adult clients. This change, known as presbycusis, is characterized by a reduced ability to hear high-pitched sounds due to changes in the inner ear, including damage to hair cells and changes in the auditory nerves. Presbycusis is a well-documented and expected age-related change in hearing.
Correct Answer is A
Explanation
Choice A rationale:
The client's statement, "I will be asked to identify different sensations, such as sharp or dull," indicates an understanding of the teaching on tactile testing. This choice demonstrates knowledge about the purpose and nature of the test, which involves identifying various sensations, including sharp or dull, to assess the client's sensory perception. The client's response aligns with the expected outcome of the teaching, showing comprehension.
Choice B rationale:
The statement, "Small needles will be inserted into one of my muscles," is not an accurate description of tactile testing. Tactile testing typically involves assessing the client's ability to perceive sensations on their skin, such as sharpness, dullness, temperature, or pressure. Inserting needles into muscles is not a part of this test, so this choice does not indicate an understanding of the teaching.
Choice C rationale:
The statement, "A dye is injected into my vein during this test," is not related to tactile testing. Tactile testing does not involve injecting dye into veins. This response suggests a misunderstanding of the purpose and procedure of the test, so it is not the correct choice.
Choice D rationale:
The statement, "I will be asleep during this test," is not consistent with tactile testing. Tactile testing is a sensory assessment that requires the client to be awake and actively participate in identifying sensations. This response indicates a lack of understanding of the test, and it is not the correct choice.
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