The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.
He states that it is painful.
This is a:
pressure injury.
stage 2.
stage 1.
stage 3.
stage 4. .
The Correct Answer is C
Choice A rationale:
A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.
Choice B rationale:
Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.
Choice C rationale:
Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.
Choice D rationale:
Stage 3 pressure injuries involve full-thickness skin loss.
Choice E rationale:
Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Restlessness, rising pulse, and falling blood pressure are classic signs of shock, which can occur with internal hemorrhage.
Choice B rationale:
Lethargy, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.
Choice C rationale:
Headache, rising pulse, and falling blood pressure could be signs of many conditions, but they are not specific to internal hemorrhage.
Choice D rationale:
Restlessness, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.
Correct Answer is C
Explanation
Choice A rationale:
Cleaning from left to right across the wound can introduce bacteria from the surrounding skin into the wound, which can lead to infection.
Choice B rationale:
Cleaning from the outer abdomen toward the wound can also introduce bacteria from the surrounding skin into the wound.
Choice C rationale:
Cleaning in a circular motion around the wound, circling to the outside, helps to move bacteria away from the wound and reduce the risk of infection.
Choice D rationale:
Cleaning directly over the wound can disrupt the healing process and potentially introduce bacteria into the wound.
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