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:
Tertiary intention, also known as delayed primary closure or secondary suture, is a type of wound healing where the wound is initially left open and closed after several days.
Choice B rationale:
The remodeling phase is not a type of wound healing, but a stage of wound healing where the wound fully closes and the new tissue slowly gains strength and flexibility.
Choice C rationale:
Primary intention is a type of wound healing where the wound edges are approximated (brought together) and the wound heals by the process of epithelialization.
Choice D rationale:
Secondary intention is a type of wound healing where the wound is left open and heals by granulation, contraction, and epithelialization.
Correct Answer is D
Explanation
Choice A rationale:
Purulent drainage is thick and often has a foul odor. It is often a sign of infection and can have a variety of colors, including yellow, green, or brown. This is not the correct choice because the description does not match the question.
Choice B rationale:
Serous drainage is clear and watery, often seen in normal healing processes. This is not the correct choice because the description does not match the question.
Choice C rationale:
Sanguinous drainage is fresh blood, often seen in deep wounds or when a wound is disturbed. This is not the correct choice because the description does not match the question.
Choice D rationale:
Serosanguineous drainage is a mixture of blood and serous fluid, often seen in new wounds. This matches the description given in the question.
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