A nurse is assessing a client with a skin condition. Which of the following describes the client’s condition?
Full thickness skin loss with visible bone.
Intact skin with localized erythema.
Partial-thickness skin loss with red tissue.
Full thickness skin loss with visible adipose tissue.
The Correct Answer is D
Choice A rationale
Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.
Choice B rationale
Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Choice C rationale
Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
Choice D rationale
Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A stoma may appear red and moist immediately after surgery, similar to the inside of the mouth. A purplish color could indicate a lack of blood supply to the stoma, which is a medical emergency.
Choice B rationale
A small amount of bleeding around the stoma is normal, especially when cleaning the area or changing the ostomy appliance. This is because the stoma contains blood vessels and has a rich blood supply.
Choice C rationale
Fecal output from a colostomy can be expected within 2 to 4 days after surgery. It is not typical to see output within 24 hours.
Choice D rationale
An increase in the intake of raw vegetables is not necessary after a colostomy. In fact, some people may find certain raw vegetables difficult to digest and they may cause gas or odor.
Correct Answer is A
Explanation
Choice A rationale
The nurse should plan to refrigerate the urine during the collection time period. This is because the urine needs to be kept cool to prevent the breakdown of certain analytes that might be measured in the urine.
Choice B rationale
The nurse should not discard the client’s last void at the end of the collection time period. The last voided specimen should be included in the collection to ensure that the 24-hour collection is complete.
Choice C rationale
The nurse should not include toilet paper with the collected urine. Toilet paper could contaminate the urine sample and interfere with the accuracy of the test results.
Choice D rationale
The nurse should not save the first void at the start of the collection time period. The first voided specimen should be discarded, and the collection should start with the next void.
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