The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.
Which term will the nurse use to describe this area?
Secondary erythema.
Nonblanchable erythema.
Blanchable hyperemia.
Reactive hyperemia.
The Correct Answer is B
Choice A rationale:
Secondary erythema refers to redness that develops after the initial injury or insult. It's not the most accurate term to describe an area that doesn't blanch, as blanching specifically assesses for the presence of blood in the tissue. Secondary erythema can be blanchable or nonblanchable, depending on the underlying cause.
Choice C rationale:
Blanchable hyperemia is a reddening of the skin that blanches (turns lighter) when pressed. This indicates that blood is still flowing to the area and that the tissue is not damaged. It's not the correct term for an area that doesn't blanch.
Choice D rationale:
Reactive hyperemia is a temporary increase in blood flow to an area that has been deprived of blood flow. It's often seen after pressure is relieved from a body part. While reactive hyperemia can cause redness, this redness typically blanches when pressed.
Choice B rationale:
Nonblanchable erythema is the most accurate term to describe an area of redness that does not turn lighter in color when pressed with a finger. This indicates that blood is not flowing to the area and that the tissue is likely damaged. Nonblanchable erythema is a significant finding because it can be a sign of a pressure injury (also known as a bedsore or pressure ulcer).
Key points about nonblanchable erythema:
It's a sign of impaired blood flow to the tissue. It's a potential indicator of a pressure injury.
It requires prompt assessment and intervention to prevent further tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Inaccurate statement: While herbal supplements are derived from plant materials, this does not inherently guarantee their safety or non-toxicity. Some plants contain potent compounds that can have adverse effects, even in small doses.
Lack of regulation: Herbal supplements are not regulated by the FDA in the same way as prescription medications. This means that there is no guarantee of their purity, potency, or consistency.
Potential for interactions: Herbal supplements can interact with prescription medications, potentially leading to harmful side effects.
Choice B rationale:
Cost-related issue: The cost of herbal supplements can vary widely. While some may be less expensive than prescription medications, others can be quite costly.
Misleading focus: Emphasizing cost as a primary factor could lead patients to prioritize affordability over safety and effectiveness.
Choice C rationale:
Addresses quality concerns: This response directly addresses the lack of stringent quality standards for herbal supplements, highlighting a significant safety concern.
Encourages informed decision-making: This response encourages patients to carefully consider the potential risks and benefits of herbal supplements, prompting them to seek reliable information and discuss their choices with healthcare providers.
Choice D rationale:
Convenience vs. safety: While the convenience of herbal supplements may be appealing, this response does not address the potential safety concerns associated with their use.
Potential for misuse: Highlighting convenience could lead to patients using herbal supplements inappropriately or without necessary guidance from healthcare professionals.
Correct Answer is B
Explanation
Choice A rationale:
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.