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 B

Explanation

Choice a reason:
Tympany is a drum-like, resonant sound that is typically heard over air-filled structures, such as the gastric bubble, not the chest. It is not a sound associated with the lungs, especially in the context of COPD.

Choice b reason:
Hyperresonance is an abnormally loud, lower-pitched sound than normal resonance heard over hyperinflated areas of the lung, such as in cases of COPD. This is due to the increased air content within the lungs, often because of overdistension or destruction of alveolar tissue, as seen in emphysema, a common type of COPD.

Choice c reason:
Resonance is the normal sound heard over healthy lung tissue when percussed. However, in the case of COPD, particularly emphysema, the destruction of lung tissue leads to hyperinflation and thus a hyperresonant sound rather than the normal resonance.

Choice d reason:
Dullness is heard when fluid or solid tissue replaces air in the lung or occupies the pleural space, as in the case of pneumonia or pleural effusion. This is not characteristic of COPD, where there is an increase in air due to the breakdown of alveolar walls.

A. Facial B. Abducens C. Glossopharyngeal D. Hypoglossal

Correct Answer is C

Explanation

Choice A Reason:
The facial nerve, or cranial nerve VII, is responsible for the taste sensation in the anterior two-thirds of the tongue, not the posterior third. It carries taste sensations from the front part of the tongue via the chorda tympani branch.

Choice B Reason:
The abducens nerve, or cranial nerve VI, has no role in taste sensation. It is primarily involved in controlling the lateral rectus muscle of the eye, which abducts the eye.

Choice C Reason:
The glossopharyngeal nerve, or cranial nerve IX, provides special sensory innervation for taste to the posterior third of the tongue. This enables the sensation of various tastes like salty, sweet, sour, and bitter in this region.

Choice D Reason:
The hypoglossal nerve, or cranial nerve XII, is responsible for motor control of the tongue muscles but does not provide sensory innervation for taste.

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Naxlex Comprehensive Predictor Exams

A client with a history of COPD is being assessed. When the nurse percusses the client's chest, which characteristic sound is expected?

Correct Answer is B

Explanation

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

Correct Answer is C

Explanation

Using the client's height of 72 inches and weight of 200 lbs, the nurse calculates the BMI. A BMI of 27 indicates which category for this patient?

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?

During an assessment of the ear structures, the nurse would expect to identify which structure as part of the middle ear?

While examining a client, the nurse observes the client's chest to be barrel-shaped. The nurse would interpret this as indicating which of the following?

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?

The nurse read the patient's health history and noted cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?

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