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 ["A","B","D"]
Explanation
The correct answer is choicea. Increase daily caloric intake by 300 to 400 calories,b. Consume folic acid supplements daily, andd. Take daily iron and calcium supplements.
Choice A rationale:
Pregnant teenagers need to increase their daily caloric intake by 300 to 400 calories to support the growth and development of the fetus.
Choice B rationale:
Folic acid is crucial for preventing neural tube defects in the developing fetus.Daily supplementation is recommended.
Choice C rationale:
Pregnant teenagers need to increase their protein intake to support fetal growth and maternal health.Maintaining current protein intake is not sufficient.
Choice D rationale:
Iron and calcium are essential for the development of the fetus and the health of the mother.Daily supplementation helps prevent deficiencies.
Choice E rationale:
Limiting weight gain to no more than 15 pounds is not recommended.Healthy weight gain during pregnancy varies but is generally higher than 15 pounds to support fetal development.
Correct Answer is B
Explanation
Choice A rationale
Excessive thirst and urination are symptoms of hyperglycemia, not hypoglycemia. Hyperglycemia could occur if the TPN solution was infusing too quickly, but it would not be a result of the infusion pump not working.
Choice B rationale
Shakiness and diaphoresis are manifestations of hypoglycemia. When a sudden interruption in the infusion of TPN occurs, the patient is at risk for hypoglycemia.
Choice C rationale
Fever and chills are symptoms of infection, not a direct result of the TPN infusion stopping.
Choice D rationale
Hypertension and crackles in the lungs are signs of fluid overload, not hypoglycemia. These symptoms would not be expected if the TPN infusion stopped.
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.