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 D

Explanation

Choice a reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. Bronchovesicular sounds do not involve the change of vowel sounds during auscultation.

Choice b reason:
Bronchophony is the term used when the voice sounds are more clear and louder over the chest wall, usually indicating lung consolidation. However, it does not specifically refer to the change of vowel sounds from "ee" to "ay."

Choice c reason:
Normal voice resonance is when voice sounds heard through auscultation are muffled and indistinct. It does not involve a clear change in vowel sounds, which is what occurs with egophony.

Choice d reason:
Egophony is characterized by the change of the "ee" vowel sound to a nasal "ay" or "a" sound when auscultating the lungs. This phenomenon typically suggests lung consolidation, as might be seen with pneumonia.

A. Resonance B. Tympanic C. Flat D. Dullness

Correct Answer is A

Explanation

Choice a reason:
Resonance is the expected percussion note when percussing over normal, healthy lung tissue. This sound is produced due to the presence of air in the lung parenchyma, which allows for the transmission of sound waves through the air-filled spaces. In a healthy individual, the resonance indicates that the lungs are free from any significant abnormalities that could alter the sound, such as fluid or solid masses.
Choice b reason:
Tympanic notes are typically heard over hollow, air-containing structures like the stomach. This sound is not expected in lung percussion unless there is a large, air-filled cavity within the lung tissue, which would be abnormal and indicative of a pathological condition such as a pneumothorax.
Choice c reason:
A flat percussion note is usually heard over dense tissues where air is not present, such as over the thigh muscles or areas of the chest where lung tissue has been replaced by something more solid, like in the case of a pleural effusion or a lung mass.
Choice d reason:
Dullness on percussion usually indicates that the lung is not air-filled and may be suggestive of underlying conditions such as pneumonia, tumor, or atelectasis. It is a higher-pitched sound compared to flatness and is typically found in areas of the lung that are filled with fluid or solid tissue rather than air.

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Naxlex Comprehensive Predictor Exams

A nurse is performing a respiratory system physical examination. To assess the resonance of voice sounds heard during auscultation of the lungs, the nurse instructs the patient to say "ee," and if the sound is heard as "ay," this is known as:

Correct Answer is D

Explanation

A nurse is performing a respiratory physical examination on a healthy patient. When performing the percussion physical assessment technique, the lung percussion note should be:

Correct Answer is A

Explanation

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

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

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