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.

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Correct Answer is C

Explanation

A) Blockage of the tear ducts causing excessive tearing:

Blockage of tear ducts (dacryostenosis) results in excessive tearing (epiphora) due to inadequate drainage of tears into the nasal cavity. It does not directly contribute to glaucoma, which primarily involves increased intraocular pressure (IOP) and optic nerve damage.

B) Inflammation of the cornea resulting in blurry vision:

Corneal inflammation (keratitis) can cause blurry vision, pain, and sensitivity to light, but it is not the primary pathophysiology of glaucoma. Glaucoma primarily involves damage to the optic nerve due to elevated IOP.

C) Increased intraocular pressure (IOP) leading to optic nerve damage:

Glaucoma is characterized by elevated IOP, which puts pressure on the optic nerve and can lead to progressive damage and vision loss if untreated. This is the primary pathophysiological process in most types of glaucoma.

D) Degeneration of the lens leading to cataracts:

Cataracts involve the clouding of the lens of the eye, leading to visual impairment. While cataracts are a common condition in older adults, they are not directly related to the pathophysiology of glaucoma, which primarily involves elevated IOP and optic nerve damage.

A. Concussions in sports and motor vehicle accidents cause the largest number of TBIS in teens. B. Females have twice the risk that males do. C. Falls occur more frequently in the younger population. D. Most firearm incidents are accidental.

Correct Answer is A

Explanation

A) Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens: Adolescents are particularly susceptible to TBIs due to their frequent involvement in contact sports like football, soccer, and hockey, as well as risky behaviors associated with driving. These activities are leading causes of TBIs in this age group, making education on safety measures and proper use of protective equipment essential in prevention efforts.

B) Females have twice the risk that males do: This statement is incorrect. In reality, males are more likely to sustain TBIs than females, especially in adolescence. The higher risk in males is largely due to their greater participation in high-impact sports and higher likelihood of being involved in motor vehicle accidents.

C) Falls occur more frequently in the younger population: Although falls are a significant cause of TBIs in young children and older adults, they are not the primary cause in adolescents. Teens are more likely to sustain TBIs from sports injuries and car accidents, making these areas more relevant for preventive education.

D) Most firearm incidents are accidental: While firearm-related TBIs can occur, they are not as common in the adolescent population compared to injuries from sports and motor vehicle accidents. Prevention efforts should focus more on the activities that pose the highest risk for this age group.

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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 pressure ulcer.

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Naxlex Comprehensive Predictor Exams

What is the primary pathophysiology of glaucoma?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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