The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of

Stage III

Stage II

Stage I

Stage IV

Answer and Explanation

The Correct Answer is D

A. Stage III: This stage involves full-thickness tissue loss extending through the subcutaneous layer but does not typically present as a blister-like superficial wound.

B. Stage II: This stage is characterized by partial-thickness skin loss involving the epidermis and/or dermis, often presenting as a blister or superficial ulcer.

C. Stage I: Stage I pressure ulcers involve intact skin with non-blanchable redness, not a break in the skin or blister.

D. Stage IV: This stage involves full-thickness tissue loss with extensive destruction, potentially exposing bone or muscle, not a superficial blister.

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

A. Rovsing sign: This sign is positive when palpation of the left lower quadrant causes pain in the right lower quadrant, indicating possible appendicitis.

B. Psoas sign: This sign is positive when pain occurs upon extending the right thigh or flexing the hip against resistance, suggesting irritation of the psoas muscle due to appendicitis.

C. Murphy sign: This sign is associated with gallbladder inflammation (cholecystitis), not appendicitis.

D. Obturator sign: This sign is positive when pain occurs upon flexing and internally rotating the right thigh, which can indicate irritation of the obturator muscle due to appendicitis.

A. Problem-oriented assessment B. Follow-up history C. Comprehensive assessment D. Emergency history

Correct Answer is B

Explanation

A. Problem-oriented assessment: This focuses on specific issues or symptoms rather than evaluating outcomes of an established care plan.

B. Follow-up history: This type of assessment is conducted to evaluate the effectiveness of interventions and monitor progress towards outcomes identified in the care plan.

C. Comprehensive assessment: This involves a thorough evaluation of the client’s overall health status and history, not specifically focused on evaluating outcomes.

D. Emergency history: This is conducted in urgent situations to quickly assess and address immediate issues, not for evaluating outcomes of a care plan.

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The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

The nurse who has been assigned to a client on the second shift is assessing a client to evaluate the outcomes identified in the care plan. This nurse is conducting which type of assessment?

Correct Answer is B

Explanation

During the physical assessment of the peripheral vascular system, a client's foot is pale when elevated and dark red when in the dependent position. The nurse is concerned that this client is at risk for developing:

Data collection occurs where in the nursing process?

A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate an understanding of the waveforms when they identify which component as indicating ventricular repolarization (relaxation).

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

When the nurse collects objective data, which finding requires immediate follow-up?

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

Cranial nerves involved in eye movements are: