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 pressure ulcer.
Stage I
Stage III
Stage IV
Stage II
The Correct Answer is D
Stage I: Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin. There is no break in the skin, but it may appear red and warm to the touch. It is considered the mildest form of pressure injury, signaling the beginning of potential skin damage.
B) Stage III: Stage III pressure ulcers involve full-thickness skin loss. This means that the damage extends through the dermis into the subcutaneous tissue. There may be visible fat, but bone, tendon, and muscle are not exposed. These ulcers are deeper and more serious than the scenario described.
C) Stage IV: Stage IV pressure ulcers are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. The presence of slough or eschar may be present on some parts of the wound bed, and these ulcers are deep, often with extensive damage and infection.
D) Stage II: Stage II pressure ulcers are characterized by partial-thickness skin loss involving the epidermis and/or dermis. They present as shallow, open ulcers with a red-pink wound bed, without slough. They may also appear as intact or open/ruptured serum-filled blisters, which matches the description given in the scenario. This stage represents a more significant injury than Stage I but does not extend into the deeper layers of skin and tissue as in Stage III and IV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "I do not eat salty foods and snacks": This statement indicates the client's dietary habits and, while it can impact overall health, it does not necessarily require immediate validation unless there is reason to doubt its accuracy or it is related to a specific health concern being addressed.
B) "My rings are not fitting on my fingers like they usually do": This statement suggests a change in the client's physical condition, likely indicating fluid retention or edema. This symptom requires validation as it could signify an underlying issue such as heart failure, kidney problems, or other medical conditions that need prompt attention.
C) "I exercise about 20 minutes a day by walking": This statement reflects the client's physical activity routine. While it's important for assessing overall health and fitness, it does not demand immediate validation unless related to a specific health issue.
D) "High blood pressure is present in my mother & grandmother": This statement provides valuable family history information, which is important for assessing genetic risk factors. However, it does not require urgent validation compared to physical changes indicating potential health problems.
Correct Answer is A
Explanation
A) Dehydration:
When the skin remains tented and returns to its normal position slowly after being pinched, it indicates decreased skin turgor, which is a clinical sign of dehydration. Dehydration can occur due to fluid loss from sweating during vigorous physical activity like a beach tournament.
B) Hypervolemia:
Hypervolemia refers to excess fluid volume in the body, which would typically manifest with signs such as peripheral edema or jugular vein distention rather than decreased skin turgor.
C) Properly Hydrated:
Properly hydrated individuals would have normal skin turgor, where the skin returns promptly to its normal position after being pinched.
D) Infection:
Skin tenting is not a specific sign of infection. Infection would typically present with localized signs such as redness, warmth, swelling, and possibly systemic signs like fever.
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