A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?
Full-thickness skin loss with visible bone.
Full-thickness skin loss with visible adipose tissue.
Skin remains intact 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 bone is characteristic of a stage 4 pressure injury, not a stage 1 pressure injury.
Choice B rationale
Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not a stage 1 pressure injury.
Choice C rationale
In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.
Choice D rationale
Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not a stage 1 pressure injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A colonoscopy is the standard investigation for colorectal cancer. It allows for the visualization of the entire colon and rectum, and can also allow for the removal of polyps and the taking of biopsies if needed.
Choice B rationale
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used to diagnose diseases of the gallbladder, biliary system, pancreas, and liver, not rectal cancer.
Choice C rationale
An upper GI series, which involves X-rays of the esophagus, stomach, and small intestine, would not be used for screening for rectal cancer.
Choice D rationale
An upper GI endoscopy, which involves the use of a flexible endoscope to visualize the esophagus, stomach, and duodenum, would not be used for screening for rectal cancer.
Correct Answer is ["A","B","D"]
Explanation
The correct answer is choicea. Increase daily caloric intake by 300 to 400 calories,b. Consume folic acid supplements daily, andd. Take daily iron and calcium supplements.
Choice A rationale:
Pregnant teenagers need to increase their daily caloric intake by 300 to 400 calories to support the growth and development of the fetus.
Choice B rationale:
Folic acid is crucial for preventing neural tube defects in the developing fetus.Daily supplementation is recommended.
Choice C rationale:
Pregnant teenagers need to increase their protein intake to support fetal growth and maternal health.Maintaining current protein intake is not sufficient.
Choice D rationale:
Iron and calcium are essential for the development of the fetus and the health of the mother.Daily supplementation helps prevent deficiencies.
Choice E rationale:
Limiting weight gain to no more than 15 pounds is not recommended.Healthy weight gain during pregnancy varies but is generally higher than 15 pounds to support fetal development.
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