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:
Fibromyalgia. Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain, fatigue, and tender points. It is not an example of acute pain. Acute pain typically has a sudden onset and is of limited duration.
Choice B rationale:
Peripheral neuropathy. Peripheral neuropathy can cause both acute and chronic pain, depending on the underlying cause. However, it is not a classic example of acute pain. Acute pain is usually associated with a specific injury or condition and has a sudden onset.
Choice C rationale:
Rheumatoid arthritis. Rheumatoid arthritis is a chronic autoimmune condition that can cause joint pain and inflammation. While it can have acute flares of pain, it is primarily considered a chronic condition. Acute pain typically results from injuries or conditions with a sudden onset.
Choice D rationale:
Surgical incision. This is the correct answer. A surgical incision represents a classic example of acute pain. It is a pain that results from a specific event, in this case, surgery, and typically has a well-defined onset and duration. Acute pain is often sharp and intense, and it resolves as the incision heals.
Correct Answer is C
Explanation
Choice A rationale:
Alcohol consumption is a modifiable risk factor that can have negative health consequences. However, it is not the primary factor to focus on when discussing ways to improve health. Excessive alcohol consumption can lead to liver disease, addiction, and other health issues, but it's not the most critical modifiable risk factor for many people.
Choice B rationale:
Family history is not a modifiable risk factor. It's essential information for assessing a person's risk for various health conditions, but it cannot be changed or improved upon. Therefore, it's not the primary focus when teaching someone how to improve their health.
Choice D rationale:
A sedentary lifestyle is a modifiable risk factor and is crucial for improving health. Prolonged inactivity can lead to various health problems, such as obesity, cardiovascular disease, and muscle weakness. While it's an important factor, it's not the top priority for improving health in this context.
Choice E rationale:
Weight is a modifiable risk factor, and it is closely related to diet and physical activity. Maintaining a healthy weight is essential for overall health, and it often involves a combination of dietary choices and physical activity. However, focusing on diet itself is more specific and directly actionable when providing health improvement advice. Now, let's move on to the next question.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.