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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Correct Answer is B

Explanation

A. To establish personal rapport with the client: While rapport is important, the primary purpose of asking about family health history is not to build a personal connection.

B. To identify diseases for which the client may be at risk: Family health history helps identify genetic or hereditary conditions that may increase the client’s risk for certain diseases.

C. To assess the client's quality of life: Family health history does not directly assess the client’s quality of life but rather their risk for specific conditions.

D. To get to know the client better: Although understanding family history can help in getting to know the client’s health context, the primary purpose is to assess risk factors.

A. False B. True

Correct Answer is B

Explanation

A. False: Tobacco use and excessive alcohol consumption are well-established risk factors for oral carcinoma. They contribute significantly to the development of oral cancers.

B. True: Both tobacco products and excessive alcohol consumption are principal risk factors for oral carcinoma due to their carcinogenic properties, making this statement accurate.

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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

The nurse is asking the client about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason?

Correct Answer is B

Explanation

Use of tobacco products and excessive alcohol consumption are principal risk factors for oral carcinoma.

Correct Answer is B

Explanation

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

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

Cranial nerves involved in eye movements are:

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

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

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?

The nurse is assessing a client's cardiovascular status within the comprehensive health history. What should the nurse include in this section of the assessment? (Select all that apply.)