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 D

Explanation

Exophthalmos:

Exophthalmos, or protruding eyeballs, is typically associated with hyperthyroidism (Graves' disease) rather than hypothyroidism. It results from the accumulation of fluid and swelling behind the eyeballs.

(b) Palpitations:

Palpitations, or rapid heartbeat, are more commonly associated with hyperthyroidism due to the increased metabolic rate and sympathetic nervous system stimulation. In hypothyroidism, bradycardia (slow heart rate) is more likely.

Diaphoresis, or excessive sweating, is not a typical finding in hypothyroidism. It is more commonly associated with conditions that cause autonomic dysfunction or hypermetabolic states.

(d) Weight gain:

Weight gain is a hallmark symptom of hypothyroidism. It occurs due to a slowing down of the metabolic rate, leading to reduced calorie expenditure and potential fluid retention.

A. Loss of vision in one eye B. Clear vision of nearby objects, but difficulty seeing distant objects C. Clear vision of distant objects, but difficulty seeing nearby objects D. Blurry vision of both distant and nearby objects

Correct Answer is C

Explanation

A) Loss of vision in one eye:

Loss of vision in one eye is not related to hyperopia (farsightedness). This condition could be due to various other causes such as retinal detachment, optic neuropathy, or trauma, but it does not describe the refractive error associated with hyperopia.

B) Clear vision of nearby objects, but difficulty seeing distant objects:

This description pertains to myopia (nearsightedness), where individuals can see nearby objects clearly but struggle with seeing distant objects. Hyperopia is the opposite, involving difficulty with near vision rather than distance vision.

C) Clear vision of distant objects, but difficulty seeing nearby objects:

Hyperopia, or farsightedness, is characterized by clear vision of distant objects while nearby objects appear blurry. This occurs because the eye's light focuses behind the retina rather than directly on it, making close-up tasks like reading challenging.

D) Blurry vision of both distant and nearby objects:

Blurry vision of both distant and nearby objects is not specific to hyperopia and may indicate other eye conditions such as astigmatism or severe refractive errors that affect overall visual acuity, rather than the specific issue of near vision seen in hyperopia.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

Correct Answer is D

Explanation

Which of the following best describes Hyperopia?

Correct Answer is C

Explanation

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