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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Facial edema: Myxedema is a severe form of hypothyroidism that is often characterized by the accumulation of mucopolysaccharides in the skin and other tissues, leading to facial and peripheral edema. This is a classic symptom of myxedema and is expected in clients with this condition.

B) Diarrhea: Diarrhea is more commonly associated with hyperthyroidism rather than hypothyroidism. Clients with myxedema typically experience constipation due to slowed gastrointestinal motility.

C) Tachycardia: Tachycardia is associated with hyperthyroidism. In contrast, myxedema is associated with bradycardia or a slow heart rate because of the overall slowing of the body's metabolic processes.

D) Heat intolerance: Heat intolerance is a symptom of hyperthyroidism. Clients with myxedema usually experience cold intolerance due to decreased metabolic activity and impaired thermoregulation.

A. Муоріа B. Normal eye movement C. Ptosis will be evident and no pupillary constriction. D. The eye cannot look to the outside side.

Correct Answer is C

Explanation

(a) Mydriasis:

While mydriasis (dilated pupil) can be associated with cranial nerve III damage, it does not fully describe the range of symptoms expected with oculomotor paralysis. Cranial nerve III controls more functions than pupil dilation, such as eyelid elevation and certain eye movements.

(b) Normal eye movement:

Cranial nerve III paralysis would result in abnormal eye movement due to the loss of control over muscles responsible for moving the eye. Expecting normal eye movement would be incorrect since the paralysis affects the eye's ability to move properly.

Cranial nerve III (oculomotor nerve) paralysis leads to ptosis (drooping eyelid) because it innervates the levator palpebrae superioris muscle. It also affects the pupillary constrictor muscles, resulting in a dilated pupil (lack of pupillary constriction), making this the most comprehensive and accurate answer.

(d) The eye cannot look to the outside side:

Inability to look to the outside (lateral movement) is typically associated with cranial nerve VI (abducens nerve) paralysis, which controls the lateral rectus muscle. Cranial nerve III primarily affects vertical and medial movements, so this is not the expected finding.

View Question and Answer

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

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

The nurse read the patient's health history cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?

Correct Answer is C

Explanation

During an assessment the nurse performs the action shown in this image. What is the purpose of this action?

A nurse measures a patient height and weight and calculate his BMI. Patient BMI is 37. Classify according to this BMI results?

A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?

A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

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.

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?