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You are assessing a client admitted from a long-term care facility. When noting a stage II pressure injury on the client's coccyx, which of the following would you expect?

A.

An area of non-blanchable redness on intact skin..

B.

An area of shallow broken skin with blistering

C.

Deep purple discoloration over intact skin

D.

An open wound with visible adipose tissue and eschar.

Answer and Explanation

The Correct Answer is B

A. An area of non-blanchable redness on intact skin is characteristic of a stage I pressure injury, not stage II. In stage I, the skin remains intact but shows redness that does not blanch when pressed.
B. An area of shallow broken skin with blistering describes a stage II pressure injury. Stage II involves partial-thickness loss of skin, which may present as a blister or shallow open ulcer, often with a pink or red wound bed.
C. Deep purple discoloration over intact skin refers to a suspected deep tissue injury, which is a different classification of pressure injury. It indicates damage to underlying tissue but does not involve a break in the skin.
D. An open wound with visible adipose tissue and eschar is indicative of a stage III pressure injury, which involves full-thickness skin loss and may expose underlying structures like fat, but not bone or muscle (which would indicate stage IV). Stage III wounds may also have eschar or slough, but stage II wounds do not.
 


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Related Questions

Correct Answer is ["125"]

Explanation

  • Determine the infusion time: The total dose is 40 mEq, and it's being infused at a rate of 10 mEq/hr.
  • Therefore, the total infusion time is 40 mEq / 10 mEq/hr = 4 hours.
  • Calculate the infusion rate in mL/hr: The total volume is 500 mL, and the infusion time is 4 hours.
  • So, the infusion rate is 500 mL / 4 hours = 125 mL/hr.

Correct Answer is C

Explanation

A. Hyperactive reflexes are not typically associated with hypokalemia. In fact, hypokalemia can lead to hyporeflexia (decreased reflexes) due to the role of potassium in nerve function.
B. Extreme thirst is more commonly associated with hypernatremia or dehydration, not specifically with hypokalemia.
C. A flattened T-wave on an ECG is a classic sign of hypokalemia. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low potassium levels can cause changes in the ECG, including a flattened T-wave.
D. Hyperactive bowel sounds are typically seen in conditions like gastroenteritis or early bowel obstruction, not directly related to hypokalemia. In fact, hypokalemia can sometimes lead to hypoactive or absent bowel sounds due to its effect on smooth muscle function.

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