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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice a reason:
The tympanic membrane, also known as the eardrum, is a critical component of the middle ear. It is a thin membrane that separates the external ear from the middle ear and vibrates in response to sound waves. These vibrations are then transmitted to the ossicles within the middle ear, which amplify and carry the sound to the inner ear.
Choice b reason:
The ear lobe is part of the external ear, not the middle ear. It is composed of soft skin and fatty tissue and does not play a role in hearing. The ear lobe serves primarily as a site for body decoration such as earrings.
Choice c reason:
The cochlea is a structure located in the inner ear. It is a spiral-shaped organ that contains the organ of Corti, the sensory organ of hearing. The cochlea converts the mechanical vibrations from the middle ear into nerve impulses that are sent to the brain.
Choice d reason:
The pinna, or auricle, is the visible part of the external ear. It is made of cartilage and skin and functions to capture sound waves and direct them into the ear canal towards the tympanic membrane.
Correct Answer is B
Explanation
Choice A Reason:
An ophthalmoscope is primarily used for examining the interior structures of the eye, such as the retina, and is not typically used for assessing near vision. It provides a view of the fundus of the eye, which is essential for diagnosing various eye conditions but does not directly assess a patient's reading or close-up vision.
Choice B Reason:
The Snellen Chart is traditionally used to measure distance visual acuity and would not be the first choice for assessing near vision. However, there are versions of the Snellen Chart or similar charts designed for near vision assessment, typically held at a reading distance of about 14 inches from the patient. These charts have rows of letters or symbols that decrease in size and are used to determine the smallest print size a person can read.
Choice C Reason:
A magazine can be a practical tool for assessing near vision informally, as it contains various sizes of print and is a good representation of everyday reading material. The nurse can ask the patient to read a specific paragraph to observe their ability to see and comprehend text at a close distance.
Choice D Reason:
A penlight is not used for assessing near vision. It is typically used to assess the pupillary light reflex or to illuminate specific areas of the eye during an examination. The penlight helps to evaluate the response of the pupils to light but does not measure the patient's ability to read or see objects up close.
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