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?
Patches of eschar cover parts of the wound.
Partial thickness skin erosion is observed with a loss of dermis and epidermis.
Ulcer extends into the subcutaneous tissue.
Intact skin appears red but not broken.
Open blister areas have a red-pink wound bed.
Localized redness in light skin will blanch with fingertip pressure.
Correct Answer : B,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Alcohol consumption, obesity, diabetes, stress, and high cholesterol are all significant risk factors for heart disease. However, smoking is not listed in this choice. Smoking is a major risk factor for heart disease as it damages the lining of the arteries, leads to the build-up of fatty deposits (atherosclerosis), and increases the risk of heart attacks and strokes.
Choice B rationale
Smoking, hypertension, obesity, diabetes, and high cholesterol are all major risk factors for heart disease. Smoking contributes to the development of atherosclerosis and increases the risk of heart attacks. Hypertension, or high blood pressure, strains the heart and blood vessels, increasing the risk of heart disease. Obesity is linked to multiple risk factors, including high cholesterol, diabetes, and hypertension. Diabetes can cause damage to blood vessels and increase the risk of cardiovascular complications. High cholesterol contributes to the formation of plaques in the arteries, leading to atherosclerosis.
Choice C rationale
Personality type is not a major risk factor for heart disease. Although certain personality traits, such as Type A behavior (characterized by competitiveness, urgency, and hostility), have been associated with increased stress and a higher risk of cardiovascular events, they are not considered primary risk factors. High cholesterol, diabetes, and smoking are significant risk factors, but this choice does not include hypertension or obesity, which are also crucial risk factors for heart disease.
Choice D rationale
Family history, hypertension, stress, and age are important risk factors for heart disease, but this choice does not include some key factors such as smoking, obesity, or diabetes. Family history of heart disease can indicate a genetic predisposition to cardiovascular conditions. Hypertension and stress contribute to cardiovascular risk, and age is a non-modifiable risk factor as the risk of heart disease increases with age. However, the absence of smoking, obesity, and diabetes makes this choice less comprehensive in assessing heart disease risk factors. .
Correct Answer is A
Explanation
Choice A rationale
Vitiligo is a condition caused by the destruction or malfunction of melanocytes, the cells responsible for producing melanin pigment. This leads to the development of white patches on the skin, as melanin is absent in these areas. Vitiligo is an autoimmune condition and can affect any part of the body, including the skin, hair, and mucous membranes.
Choice B rationale
Excess apocrine glands in the feet are not related to vitiligo. Apocrine glands are sweat glands found primarily in the underarm and genital areas and are responsible for the secretion of a thick, odorless fluid. Their overactivity does not result in the white patches seen in vitiligo.
Choice C rationale
Impetigo is a bacterial skin infection characterized by red sores, blisters, and crusting. It is not related to vitiligo and does not cause depigmentation. Impetigo is treated with antibiotics, whereas vitiligo requires different management strategies to address the loss of pigment.
Choice D rationale
Vitiligo is not caused by an excess of melanin pigment. Rather, it is the result of melanin loss or the absence of melanocytes in certain areas of the skin, leading to the characteristic white patches.
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