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 A
Explanation
Choice A rationale:
Administering IV medication via an oral route is a medication error and should be reported.
Choice B rationale:
A client vomiting their morning medications is an adverse event, but not all adverse events require an incident report. The nurse should assess the situation and report if it poses a risk to the patient's health.
Choice C rationale:
Administering a lipid-lowering medication to a client one hour after the scheduled time is a medication error, but again, the need for an incident report depends on the potential harm to the patient. In some cases, reporting this incident may be necessary.
Choice D rationale
An allergic reaction can occur in clients with no known drug allergies. Unless a drug was given in known allergies, it does not require an incident report.
Correct Answer is C
Explanation
Choice A rationale:
Abstract thinking develops during Piaget's formal operational stage, not the preoperational stage. The preoperational stage is characterized by symbolic thinking and egocentrism but lacks the ability for abstract thought.
Choice B rationale:
Concrete operational thinking is focused on logical and systematic thinking related to concrete objects and events, and it does not involve abstract thinking. Abstract thinking, including hypothetical and deductive reasoning, is a feature of the formal operational stage.
Choice C rationale:
Abstract thinking and formal operational thought develop during Piaget's formal operational stage, which typically begins in adolescence and continues into adulthood. This stage is characterized by the ability to think logically, solve complex problems, and consider abstract concepts.
Choice D rationale:
The sensorimotor stage is the earliest stage in Piaget's theory of cognitive development, and it is primarily concerned with sensory and motor exploration. Abstract thinking is not a component of this stage. .
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