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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.

Answer and Explanation

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.

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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.

A. reconstruction. B. maturation. C. proliferation. D. inflammation.

Correct Answer is D

Explanation

Choice A rationale:

Reconstruction is incorrect because it is not the second stage of wound healing.

Choice B rationale:

Maturation is incorrect because it is not the second stage of wound healing.

Choice C rationale:

Proliferation is incorrect because it is not the second stage of wound healing.

Choice D rationale:

Inflammation is the correct answer because it is the second stage of wound healing.

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A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

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A nurse is collecting data on a client who has a stage 1 pressure injury.
Which of the following findings should the nurse expect?