When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin with erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?

Stage IV

Stage III

Stage I

Stage II

Answer and Explanation

The Correct Answer is D

The correct answer is d) Stage II.
Choice a reason:
Stage IV pressure ulcers are the most severe, with full-thickness skin loss and exposed bone, tendon, or muscle. Signs of stage IV include large-scale tissue loss, possibly including slough or eschar, and may include undermining and tunneling. The scenario described does not indicate such an advanced stage, as there is no mention of exposed deeper tissues or structures.
Choice b reason:
Stage III pressure ulcers involve full-thickness skin loss, potentially affecting subcutaneous tissue but not extending to underlying muscle or bone. The wound may have a crater-like appearance. The described condition does not match stage III, as there is no indication of the ulcer extending into subcutaneous tissue.
Choice c reason:
Stage I pressure ulcers present with intact skin and non-blanchable redness of a localized area usually over a bony prominence. The skin may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. In the given scenario, the skin is not intact, ruling out stage I.
Choice d reason:
Stage II pressure ulcers are characterized by partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. They may also present as intact or ruptured blisters. The description of the skin condition with erythema, serosanguineous drainage, and a blister-like appearance aligns with a stage II pressure ulcer.

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Correct Answer is C

Explanation

Choice a reason:
A penlight is used to provide illumination during an examination, not to move the tongue. It helps the nurse to visualize the mouth floor and other areas by casting light, but it does not have the physical structure to manipulate the tongue.

Choice b reason:
Gloves are worn by healthcare professionals to maintain hygiene and protect both the patient and the nurse from the transmission of infectious agents. They are not used to move the tongue to one side during an examination.

Choice c reason:
A gauze pad is the correct tool to use when the nurse needs to move the tongue to one side during an examination of the mouth floor. The nurse can wrap the gauze pad around the tongue for a better grip, which allows for safe and effective retraction of the tongue without causing discomfort to the patient.

Choice d reason:
A tongue blade, also known as a tongue depressor, is typically used to depress the tongue to examine the back of the throat, not to move the tongue to one side. It is used to hold the tongue down so that the nurse can inspect the oropharynx and other structures.

A. Obtain and check needed equipment. B. Turn on relaxing music of the client's choice. C. Identify ways to ensure client privacy. D. Wash hands. E. Dim the lighting to promote comfort.

Correct Answer is ["A","C","D"]

Explanation

Choice a reason:
Obtaining and checking the needed equipment is essential before conducting a physical examination. This ensures that all necessary tools are functional and readily available, which facilitates a smooth and efficient assessment process. It also minimizes interruptions that could cause discomfort or anxiety for the client.
Choice b reason:
While turning on relaxing music of the client's choice may create a calming environment, it is not a standard procedure before a physical examination. Music preferences are subjective, and what is relaxing for one person may be distracting for another. Additionally, music could interfere with the ability to hear heart, lung, or bowel sounds during auscultation.
Choice c reason:
Identifying ways to ensure client privacy is a fundamental nursing responsibility. It respects the client's dignity and promotes a sense of safety and comfort. Privacy can be ensured by closing curtains, securing the area, and making sure the examination is conducted in a private setting.
Choice d reason:
Washing hands is a critical step before any physical examination. It is a primary measure for infection control, protecting both the nurse and the client from potential transmission of microorganisms.
Choice e reason:
Dimming the lighting to promote comfort is not typically recommended before a physical examination. Adequate lighting is crucial for the inspection phase of the examination, allowing the nurse to observe the client's general appearance, skin color, and other physical characteristics accurately.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to examine a client's mouth floor. To move the tongue to one side for this examination, which tool should the nurse use?

Correct Answer is C

Explanation

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

The nurse working in the eye doctor's office is completing an assessment on an elderly client. Which of the following would a nurse expect to assess in a client with esotropia?

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?