A nurse is collecting data on a client who has a stage 1 pressure injury.
Which of the following findings should the nurse expect?
Full thickness skin loss with visible adipose tissue.
Full thickness skin loss with visible bone.
Intact skin with localized erythema.
Partial-thickness skin loss with red tissue in the wound bed.
The Correct Answer is C
Choice A rationale:
Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.
Choice B rationale:
Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.
Choice C rationale:
Stage 1 pressure injuries are characterized by intact skin with localized erythema.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Dakin’s solution is used for chemical debridement, which involves the use of a chemical, such as Dakin’s solution, to break down and remove dead tissue.
Choice B rationale:
Primary intention is a term used to describe the healing of a clean wound without tissue loss. Dakin’s solution does not directly contribute to this process.
Choice C rationale:
While Dakin’s solution can aid in the healing process by preventing and treating infections, it does not directly cause healing.
Choice D rationale:
Phagocytosis is a process carried out by certain cells in the body to engulf and destroy pathogens or debris. Dakin’s solution does not perform this function.
Correct Answer is C
Explanation
Choice A rationale:
A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.
Choice B rationale:
Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.
Choice C rationale:
Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.
Choice D rationale:
Stage 3 pressure injuries involve full-thickness skin loss.
Choice E rationale:
Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.
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