A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?
Stage I Pressure Ulcer
Stage II Pressure Ulcer
Stage IV Pressure Ulcer
Stage III Pressure Ulcer
The Correct Answer is B
Choice A rationale: Stage I pressure ulcers consist of non-blanching erythema with an intact epidermis unlike in the above picture.
Choice B rationale: This is correct since Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers as shown in the image above.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Using the axilla to bear body weight can lead to nerve damage and is not a proper crutch technique.
Choice B rationale: Keeping the elbows extended can lead to discomfort and poor crutch control. The elbows should be slightly flexed.
Choice C rationale: When getting up from a chair, extending the uninjured leg first is not the correct technique. The patient should keep the injured leg extended for stability.
Choice D rationale: Placing weight on the unaffected leg first when climbing stairs is the correct technique, allowing for better balance and stability.
Correct Answer is A
Explanation
Choice A rationale: Dark amber, cloudy, and unpleasant-smelling urine may indicate a urinary tract infection.
Choice B rationale: Urinary retention is not typically associated with dark amber, cloudy urine.
Choice C rationale: Cloudy urine may be associated with urinary incontinence but is not typically dark amber with an unpleasant odor.
Choice D rationale: Urinary frequency does not typically cause dark amber, cloudy urine.
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