What should a nurse include in a nutrition class for pregnant teenagers? Choose all that apply.

Choice A rationale

Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.

Choice B rationale

Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice C rationale

Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale

Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice A rationale

The nurse should plan to refrigerate the urine during the collection time period. This is because the urine needs to be kept cool to prevent the breakdown of certain analytes that might be measured in the urine.

Choice B rationale

The nurse should not discard the client’s last void at the end of the collection time period. The last voided specimen should be included in the collection to ensure that the 24-hour collection is complete.

Choice C rationale

The nurse should not include toilet paper with the collected urine. Toilet paper could contaminate the urine sample and interfere with the accuracy of the test results.

Choice D rationale

The nurse should not save the first void at the start of the collection time period. The first voided specimen should be discarded, and the collection should start with the next void.