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 C
Explanation
Choice A rationale:
Administering a scheduled pain medication for a client who is in pain is an act of beneficence rather than autonomy. Beneficence focuses on doing good for the patient, while autonomy involves respecting the patient's right to make choices about their care.
Choice B rationale:
Fulfilling a promise to a client to return with their pain medication is related to veracity and accountability rather than autonomy. Autonomy pertains to the patient's ability to make choices regarding their care.
Choice D rationale:
Providing nonpharmacological pain interventions equally to all clients is related to justice and fairness rather than autonomy. Autonomy involves respecting an individual's right to make decisions about their treatment. Now, let's move on to the next question.
Correct Answer is B
Explanation
Choice A rationale:
Widened peripheral vision. This choice is not an expected change in an older adult's vision. As individuals age, peripheral vision may diminish, but it doesn't typically widen. Therefore, this choice is not appropriate.
Choice C rationale:
Eyes with large pupils. Older adults often experience changes in the size of their pupils due to the aging process. Pupils may become smaller and less responsive to light, not larger. Thus, this choice is not accurate.
Choice D rationale:
Infections of the eye. While eye infections can occur in any age group, there's no specific reason to monitor an older adult for eye infections unless there are signs or symptoms suggesting an issue. It's not a routine aspect of care for older adults. Now, let's discuss the rationale for the correct answer, choice B:
Choice B rationale:
Increase in accommodation to near vision. This is the correct answer because it is a common age-related change in vision known as presbyopia. As individuals age, their ability to accommodate or focus on near objects diminishes. This change typically begins in the early 40s and progresses over time. It's a result of the lens of the eye becoming less flexible. Older adults may need reading glasses or bifocals to improve their near vision. The nurse should plan to monitor for this change as part of routine care for an older adult.
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.