A nurse is performing an assessment on the fingers and toes of a patient.
What finding is consistent with clubbing?

Decreased angle between the cuticles and the nails.

Upward curving of the nails.

Blue nails.

Angle of nails > 160 degrees.

Answer and Explanation

The Correct Answer is D

Choice A rationale

A decreased angle between the cuticles and the nails is not indicative of clubbing. In fact, it is often associated with healthy nails. Clubbing is recognized by changes that increase the angle between the nail bed and the cuticle.

Choice B rationale

An upward curving of the nails, known as koilonychia or spoon nails, is not characteristic of clubbing but is often associated with iron-deficiency anemia. Hence, this answer is incorrect for clubbing.

Choice C rationale

Blue nails indicate cyanosis, which is related to a lack of oxygen in the blood. This is distinct from clubbing, which is more about the shape and angle of the nails rather than their color.

Choice D rationale

Clubbing is recognized by an increase in the angle between the nail bed and the cuticle, often greater than 160 degrees. This is a hallmark feature and the correct indicator of clubbing.

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Correct Answer is ["B","E"]

Explanation

Choice A rationale

Patches of eschar covering parts of the wound are characteristic of more advanced pressure ulcers, such as Stage III or IV, where necrotic tissue is present. Eschar is a dark, thick, leathery scab or crust that indicates deeper tissue damage and is not observed in Stage II pressure ulcers.

Choice B rationale

A Stage II pressure ulcer is characterized by partial thickness skin erosion with loss of the epidermis and dermis. It appears as a shallow open ulcer with a red-pink wound bed, indicating that the damage has not extended beyond these layers of skin.

Choice C rationale

When a pressure ulcer extends into the subcutaneous tissue, it is classified as a Stage III or IV ulcer, depending on the depth and extent of tissue involvement. Stage II ulcers are limited to the epidermis and dermis and do not reach the subcutaneous layer.

Choice D rationale

Intact skin that appears red but is not broken is indicative of a Stage I pressure ulcer, which represents the earliest stage of pressure injury. Stage I ulcers involve non-blanchable erythema (redness) but no open wound or skin erosion.

Choice E rationale

Open blister areas with a red-pink wound bed are characteristic of Stage II pressure ulcers. These ulcers exhibit partial thickness skin loss and can present as open or fluid-filled blisters with a visible wound bed.

Choice F rationale

Localized redness in light skin that blanches with fingertip pressure is typical of a Stage I pressure ulcer. Blanching erythema indicates that the skin is still viable and blood flow is present, which differentiates Stage I from more advanced stages of pressure injury.

A. 2nd intercostal space. B. 3rd intercostal space. C. 2nd rib. D. 4th intercostal space.

Correct Answer is A

Explanation

Choice A rationale

The Angle of Louis, also known as the sternal angle, is located at the level of the 2nd intercostal space. It is a significant landmark in clinical examinations because it is used to locate important areas of the chest, such as the aortic and pulmonic areas, for auscultation.

Choice B rationale

The 3rd intercostal space is not the correct location for the Angle of Louis. The sternal angle is found at the level of the 2nd intercostal space, not the 3rd. Therefore, this option is incorrect.

Choice C rationale

The 2nd rib attaches at the level of the Angle of Louis. The sternal angle is an anatomical landmark where the manubrium and the body of the sternum meet, and it corresponds with the attachment of the 2nd rib.

Choice D rationale

The 4th intercostal space is not the correct location for the Angle of Louis. The sternal angle is located at the 2nd intercostal space, not the 4th. Therefore, this option is incorrect. .

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A nurse is performing an assessment on the fingers and toes of a patient.What finding is consistent with clubbing?

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Naxlex Comprehensive Predictor Exams

A patient has been admitted to the hospital after the staff at a nursing home noticed a pressure ulcer on his sacral area.The nurse examines the sacral ulcer and determines it is a Stage II ulcer.Which of these findings is characteristic of a Stage II pressure ulcer?

Correct Answer is ["B","E"]

Explanation

During cardiac examination of a client, the nurse was demonstrating to the student nurse where to locate the Angle of Louis to listen to the Aortic and Pulmonic area on the chest.The nurse should locate the Angle of Louis at the level of what rib?

Correct Answer is A

Explanation

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A nurse is performing an assessment on the fingers and toes of a patient.
What finding is consistent with clubbing?