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:
Allowing extra time to communicate with the client is a crucial action when caring for a client with impaired speech. This approach respects the client's autonomy and ensures that they have the time they need to express themselves. It is an appropriate and compassionate response to the client's condition.
Choice B rationale:
Finishing sentences for the client is not recommended because it interferes with the client's ability to communicate independently. It does not respect the client's autonomy and may lead to frustration.
Choice C rationale:
Avoiding the use of visual aids for communication is not a best practice, especially for clients with impaired speech. Visual aids can enhance communication and should be used when appropriate.
Choice D rationale:
Asking open-ended questions is a good communication strategy, but it is not the first action to take. Allowing extra time for communication should be the initial step when caring for a client with impaired speech.
Correct Answer is C
Explanation
Choice A rationale:
Dysphagia is a difficulty or discomfort with swallowing and is not a complication of diverticulitis. Diverticulitis typically involves inflammation or infection of diverticula in the colon and may present with symptoms such as abdominal pain, fever, and changes in bowel habits, but dysphagia is not a characteristic feature.
Choice B rationale:
Ulcerative colitis is a distinct inflammatory bowel disease and is not a complication of diverticulitis. These conditions have different causes and affect different parts of the digestive tract. While both conditions can cause abdominal discomfort, they are not directly related.
Choice C rationale:
Peritonitis is a potential complication of diverticulitis. When diverticula become infected and rupture, they can spill their contents into the abdominal cavity, leading to peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity). This condition can be life-threatening and requires prompt medical intervention.
Choice D rationale:
Crohn's disease is a separate inflammatory bowel disease and is not a complication of diverticulitis. Crohn's disease can affect any part of the digestive tract, whereas diverticulitis typically occurs in the colon. They have distinct clinical features and treatment approaches. .
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