A nurse is attending to a patient who is unable to move.
Which stage of pressure injuries is most likely indicated by the presence of non-blanchable erythema on the patient’s heels?
Stage I pressure injury.
Stage II pressure injury.
Stage III pressure injury.
Stage IV pressure injury.
The Correct Answer is A
Choice A rationale
Stage I pressure injury is characterized by non-blanchable erythema of intact skin. This means that the skin does not turn white when pressed and is a sign of damage to the underlying
tissues. This stage is often seen in areas of the body that are under constant pressure, such as the heels in a patient who is unable to move.
Choice B rationale
Stage II pressure injury involves partial-thickness loss of skin with exposed dermis. This stage is more severe than stage I and would present with an open wound, which is not described in the question.
Choice C rationale
Stage III pressure injury involves full-thickness loss of skin, in which fatty tissue is visible in the wound. This stage is more severe than both stages I and II and would present with a deeper wound, which is not described in the question.
Choice D rationale
Stage IV pressure injury involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. This is the most severe stage of pressure injury and would present with a very deep wound exposing underlying structures, which is not described in the question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Celecoxib, like other NSAIDs, can increase the risk of serious gastrointestinal (GI) adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Black, tarry stools can be a sign of GI bleeding.
Choice B rationale
Dry mouth is not typically associated with celecoxib use.
Choice C rationale
Polyuria, or excessive urination, is not typically associated with celecoxib use.
Choice D rationale
Bone pain is not typically a side effect of celecoxib. Celecoxib is used to relieve pain from various conditions, including osteoarthritis.
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale
Standing directly in front of a patient who has a history of anger and aggression can be perceived as threatening and may escalate the situation.
Choice B rationale
Knowing the layout of the facility can help the nurse to plan for safe exits or to put barriers between themselves and the patient if needed.
Choice C rationale
Bringing security for all patient interactions can escalate the situation and should only be done if there is a clear threat to safety.
Choice D rationale
Providing immediate verbal feedback for escalating behavior can help to de-escalate the situation and reassure the patient.
Choice E rationale
Avoiding wearing necklaces during patient care can reduce the risk of injury to the nurse.
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