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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: Elevating the head of the bed is not the recommended action when moving a client up in bed.
Choice B rationale: Having the client fold the arms across the chest is not the primary action when moving a client up in bed.
Choice C rationale: Asking another nurse about the plan of care is not necessary in this situation and does not directly address the action needed when moving the client.
Choice D rationale: Maintaining a pillow under the client's head helps provide comfort and support during the movement.

A. Calcium B. Vitamin B1 C. Protein D. Vitamin D

Correct Answer is C

Explanation

Choice A rationale: Calcium is essential for bone health but is not specifically emphasized in wound healing.
Choice B rationale: Vitamin B1 is important for energy metabolism but is not specifically emphasized in wound healing.
Choice C rationale: Protein is crucial for wound healing as it provides the building blocks for tissue repair and regeneration.
Choice D rationale: Vitamin D is important for bone health but is not specifically emphasized in wound healing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When moving a client up in bed with the assistance of another caregiver, the nurse should:

Correct Answer is B

Explanation

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Correct Answer is C

Explanation

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