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: Protective supine positioning is not ideal for managing dysphagia or facilitating swallowing.
Choice B rationale: Semi-Fowlers positioning, with the head of the bed elevated at a 30 to 45-degree angle, is often recommended for clients with dysphagia. This position helps prevent aspiration during eating and promotes effective swallowing.
Choice C rationale: Low-Fowlers and Fowlers positions may not be as effective in preventing aspiration during eating as the Semi-Fowlers position.
Choice D rationale: Fowlers positioning alone may not be sufficient for managing dysphagia; Semi-Fowlers is a more specific recommendation.

A. "You are experiencing stress incontinence. Do you know how to do Kegel exercises?" B. "You are experiencing transient incontinence. Have you been administered diuretics or IV fluids lately?" C. "You are experiencing total incontinence. Have you had any surgeries or trauma that may be causing this?" D. "You are experiencing reflex incontinence. Have you had a spinal cord injury in the past?"

Correct Answer is D

Explanation

Choice A rationale: Stress incontinence is characterized by involuntary urine leakage during activities that increase intra-abdominal pressure, such as coughing or sneezing.
Choice B rationale: Transient incontinence is temporary and often related to factors like medications or medical conditions.
Choice C rationale: Total incontinence refers to continuous and unpredictable leakage of urine.
Choice D rationale: Reflex incontinence is associated with neurologic dysfunction, and the lack of warning or stress preceding involuntary urination aligns with this description.

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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

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but the care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Correct Answer is B

Explanation

Reflex incontinence is associated with neurologic dysfunction and occurs when no warning or stress precedes periodic involuntary urination.

Correct Answer is D

Explanation

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

A client with a urinary tract infection is to be discharged from the healthcare facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client makes which statement?

A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

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?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?