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The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.
You would document this wound as:

stage 1.

unstageable.

deep tissue injury.

stage 2.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.

Choice B rationale:

Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Choice C rationale:

Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Choice D rationale:

A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

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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.

A. reconstruction. B. maturation. C. proliferation. D. inflammation.

Correct Answer is D

Explanation

Choice A rationale:

Reconstruction is incorrect because it is not the second stage of wound healing.

Choice B rationale:

Maturation is incorrect because it is not the second stage of wound healing.

Choice C rationale:

Proliferation is incorrect because it is not the second stage of wound healing.

Choice D rationale:

Inflammation is the correct answer because it is the second stage of wound healing.

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The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.You would document this wound as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.
You would document this wound as: