What would be considered early signs/symptoms of pressure injury (Stage 1)?
Intact skin with nonblanchable redness, painful,warm, soft localized area over a bony prominence
Shallow, open, shiny, dry injury, pink-red wound bed without sloughing or bruising
Full-thickness tissue loss, slough and black eschar in wound bed with undermining and tunneling
Full-thickness tissue loss, subcutaneous fat visible, possible undermining and tunneling
The Correct Answer is A
A. Intact skin with nonblanchable redness, painful, warm, soft localized area over a bony prominence
Stage 1 pressure injuries are characterized by intact skin with nonblanchable redness over a localized area, typically over a bony prominence like the sacrum, heel, or elbow. The skin may feel painful, warm, and soft to the touch. Nonblanchable redness means that when pressure is applied to the area, the redness does not fade or blanch (turn white). This stage indicates that tissue damage has occurred, but the skin is still intact.
B. Shallow, open, shiny, dry injury, pink-red wound bed without sloughing or bruising: This description is more indicative of a Stage 2 pressure injury, which involves partial-thickness skin loss with an intact or ruptured blister. The wound bed is usually pink or red, and there is no sloughing or bruising.
C. Full-thickness tissue loss, slough and black eschar in wound bed with undermining and tunneling: This description corresponds to a Stage 3 or Stage 4 pressure injury. Stage 3 involves full-thickness tissue loss with visible subcutaneous fat but no bone, tendon, or muscle exposed. Stage 4 involves extensive tissue loss with exposure of bone, tendon, or muscle. Both stages may include slough (yellow or white tissue) and black eschar (hard, necrotic tissue), along with undermining (tissue destruction under intact skin edges) and tunneling (narrow passageways extending from the wound).
D. Full-thickness tissue loss, subcutaneous fat visible, possible undermining and tunneling: This description also corresponds to a Stage 3 pressure injury, as it involves full-thickness tissue loss with visible subcutaneous fat. The mention of possible undermining and tunneling further suggests a Stage 3 pressure injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Urine output is greater than 0.5 mL/kg/hr
During the fluid resuscitation phase of burn management, one of the primary goals is to maintain adequate tissue perfusion and organ function by ensuring sufficient fluid intake. The best method for assessing the results of fluid resuscitation is by monitoring urine output. A urine output of greater than 0.5 mL/kg/hr is indicative of adequate renal perfusion and kidney function, suggesting that fluid resuscitation is effective in maintaining tissue perfusion and preventing complications such as acute kidney injury.
B. Serum hemoglobin is 11 gm/dL
Serum hemoglobin levels can be affected by various factors, including fluid resuscitation, blood loss, and other medical conditions. While monitoring hemoglobin levels is important in overall patient assessment, it is not the best method specifically for assessing the results of fluid resuscitation during the initial phase of burn management.
C. Breath sounds are clear bilaterally
Clear bilateral breath sounds indicate adequate lung function and ventilation but may not directly reflect the effectiveness of fluid resuscitation in maintaining tissue perfusion. Lung sounds can be influenced by factors such as lung injury from smoke inhalation or mechanical ventilation settings, which may not correlate directly with fluid resuscitation outcomes.
D. Heart rate is 122/min
Heart rate can be influenced by various factors such as pain, stress, medications, and underlying medical conditions. While monitoring heart rate is important in assessing patient status, it is not the most reliable method for specifically evaluating the results of fluid resuscitation during the fluid resuscitation phase of burn management.
Correct Answer is B
Explanation
A. Elevated hemoglobin:
Elevated hemoglobin levels are not typically associated with aging or factors that affect pressure injury healing. Hemoglobin levels primarily relate to blood oxygen-carrying capacity and are influenced by factors such as hydration status, kidney function, and certain medical conditions.
B. Decreased protein level:
This is a significant factor that can impact the ability of a pressure injury to heal in older adults. Decreased protein levels, specifically serum albumin and total protein, are common in aging individuals and can contribute to impaired wound healing. Protein is essential for tissue repair, collagen synthesis, and immune function.
C. Low bone density:
While low bone density (osteoporosis) is a concern in aging adults and can increase the risk of fractures, it is not directly related to the ability of a pressure injury to heal. However, bone density can indirectly impact wound healing if fractures or bone-related complications occur.
D. Increased muscle mass:
Increased muscle mass is generally beneficial for overall health and functional abilities in older adults. However, it is not directly related to the ability of a pressure injury to heal.
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.