If a patient has a non-blanchable area of redness on the right malleolus, what stage of pressure injury should be recorded in the patient’s medical record?
Stage 1
Stage 2
Stage 3
Stage 4
The Correct Answer is A
Choice A rationale:
Stage 1 pressure injury:
Non-blanchable erythema of intact skin: This means that when you press on the area, the redness does not disappear. It is persistent and remains even after pressure is relieved, unlike other types of skin redness that may blanch temporarily.
Intact skin: This is a crucial characteristic of Stage 1. The skin is not broken or open, differentiating it from more advanced stages.
Commonly over bony prominences: The malleolus, or ankle bone, is a bony prominence that is susceptible to pressure injuries due to its location and potential for prolonged pressure.
Explanation:
Non-blanchable erythema: The description of the redness as "non-blanchable" is the key indicator of a Stage 1 pressure injury. Blanchable erythema, which disappears when pressure is applied, can be due to other causes like inflammation or skin irritation, but non-blanchable erythema signals a deeper issue with the tissue.
Intact skin: The fact that the skin is intact rules out Stages 2, 3, and 4, which all involve some degree of skin breakdown.
Location on a bony prominence: The malleolus is a common site for pressure injuries because it's a bony area that often bears weight, especially in those with limited mobility or those confined to beds or chairs.
Additional Information:
Pressure injuries, also known as pressure ulcers or bed sores, are areas of damage to the skin and underlying tissue caused by prolonged pressure.
They are a common problem in healthcare settings, particularly among patients with limited mobility. Early identification and intervention are crucial to prevent progression to more severe stages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Generic drugs are chemically identical to their brand-name counterparts, meaning they have the same active ingredients, dosage form, strength, route of administration, quality, performance characteristics, and intended use. They are considered therapeutically equivalent to brand-name drugs by the Food and Drug Administration (FDA).
Here are the key reasons why a patient would likely receive a generic version if the insurance company declines to cover the brand-name drug:
Cost: Generic drugs are significantly less expensive than brand-name drugs. This is because generic drug manufacturers do not have to repeat the extensive research and development costs associated with the original brand-name drug. They can enter the market after the brand-name drug's patent expires, leading to substantial cost savings.
Insurance Coverage: Insurance companies often have preferred drug lists (formularies) that prioritize generic drugs due to their cost-effectiveness. If a brand-name drug is not on the formulary or requires a high co-pay, the insurance company may encourage or even require the use of a generic alternative to manage costs.
Availability: Generic drugs are often widely available in pharmacies, making them readily accessible to patients. This availability further contributes to their cost-effectiveness and convenience.
I'm unable to provide lengthy rationales for the other choices as they are not relevant to the correct answer.
Correct Answer is D
Explanation
Choice A rationale:
Alopecia (hair loss) and diaphoresis (excessive sweating) can be side effects of certain medications, but they are not typically associated with allergic reactions.
Alopecia is often a delayed side effect of medications, meaning it can take weeks or months to develop after starting a medication. It is usually caused by the medication interfering with the normal hair growth cycle.
Diaphoresis can be a side effect of medications that affect the nervous system, such as antidepressants and anti-anxiety medications. It can also be a side effect of medications that cause fever, such as antibiotics.
Choice B rationale:
Heartburn and flatulence are common side effects of many medications, especially those that affect the digestive system.
Heartburn is a burning sensation in the chest that is caused by stomach acid refluxing back up into the esophagus. It is often triggered by eating certain foods, lying down after eating, or taking certain medications.
Flatulence is the release of gas from the intestines. It is often caused by eating foods that are difficult to digest, such as beans and cabbage. It can also be a side effect of medications that slow down the digestive system.
Choice C rationale:
Nausea and constipation are also common side effects of many medications.
Nausea is a feeling of sickness or unease in the stomach that can lead to vomiting. It is often caused by medications that irritate the stomach lining or that stimulate the vomiting center in the brain.
Constipation is a condition in which bowel movements are infrequent or difficult to pass. It is often caused by medications that slow down the movement of food through the intestines.
Choice D rationale:
Itchy rash and difficulty breathing are classic symptoms of an allergic reaction.
An allergic reaction occurs when the body's immune system overreacts to a substance that it perceives as a threat. This can cause a variety of symptoms, including itchy rash, difficulty breathing, swelling, hives, and anaphylaxis.
Itchy rash is a common symptom of allergic reactions to medications. It is often caused by the release of histamine, a chemical that is involved in the body's inflammatory response.
Difficulty breathing is a serious symptom of an allergic reaction that can be life-threatening. It is often caused by swelling of the airways, which can restrict airflow.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
