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 firm toothbrush is not recommended for plaque removal as it can damage the gums and tooth enamel. Soft-bristled toothbrushes are preferred because they are effective at removing plaque while being gentle on the gums and enamel.

Choice b reason:
Brushing more than twice per day does not necessarily irritate the gums unless done with improper technique or with a hard-bristled toothbrush. It is important to brush gently with a soft-bristled toothbrush and to use fluoride toothpaste to maintain oral hygiene and prevent gingivitis.

Choice c reason:
Ensuring that dental restorations such as fillings and crowns fit well is crucial in preventing gingivitis. Poorly fitted restorations can trap food particles and bacteria, leading to plaque buildup and gum inflammation. Regular dental check-ups can help ensure that restorations remain intact and do not contribute to gingivitis.

Choice d reason:
Flossing should not be avoided even if there is bleeding at the gumline. Bleeding can be a sign of gingivitis, and flossing can help remove the plaque and bacteria causing the inflammation. If bleeding persists, it is important to consult a dentist.

A. "I should get a longer cord for my telephone." B. "I should place a throw rug over electrical cords." C. "It is a good idea to use the handrails in the bathroom." D. "I should use chairs without armrests."

Correct Answer is C

Explanation

Choice a reason:
Getting a longer cord for the telephone may reduce the risk of tripping over a short cord but could potentially introduce new tripping hazards if not managed properly. It's important to keep cords secured and out of walkways to prevent falls.

Choice b reason:
Placing a throw rug over electrical cords is not advisable as it can create a tripping hazard. Rugs should be secured with non-slip backing and kept away from high-traffic areas to prevent falls.

Choice c reason:
Using handrails in the bathroom is a recommended safety measure to prevent falls. Bathrooms can be slippery, and handrails provide support and stability for residents when moving around in this area.

Choice d reason:
Using chairs without armrests is not a recommended practice for fall prevention. Chairs with armrests can aid residents in safely sitting down and standing up, providing support and reducing the risk of falls.

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Naxlex Comprehensive Predictor Exams

A nurse prepares an educational session on the importance of oral hygiene. Which teaching tip should be included in the section about preventing gingivitis?

Correct Answer is C

Explanation

A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

Correct Answer is C

Explanation

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

The clinical nurse is precepting a group of students, and one student questions the nurse, "What is the primary purpose of health assessment?" What is the most appropriate response by the clinical nurse?

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

What cranial nerve is responsible for the taste sensation of the posterior third of the tongue?

The student nurse is reviewing different types of health history. Which client situation would require an Emergency health history?

The nurse knows the importance of assessing vital signs is to:

While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?