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:
Trust vs. Mistrust is the first stage of Erikson's theory of psychosocial development and typically occurs in infancy. It is characterized by the child's development of trust or mistrust based on the caregiver's reliability and care. This stage is not relevant to an adolescent who is rebelling against caregivers and spending more time with friends.
Choice B rationale:
Identity vs. Role Confusion is the stage of Erikson's theory that corresponds to adolescence. During this stage, adolescents seek to establish a sense of identity and may experiment with different roles and behaviors. They often question who they are and what they want to become. Rebelling against caregivers and seeking independence are common characteristics of this stage.
Choice C rationale:
Integrity vs. Despair is the final stage of Erikson's theory and occurs in late adulthood. It involves reflecting on one's life and coming to terms with the choices made. It is not relevant to the situation of an adolescent client.
Choice D rationale:
Autonomy vs. Shame and Doubt is the stage that typically occurs in early childhood, where children are developing a sense of independence and autonomy. This stage is not relevant to the adolescent client's experience of rebellion and seeking autonomy.
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