A Black patient who is immobile presents with a decubitus ulcer. Which of the following is incorrect about pressure ulcer staging?
The stage of an ulcer cannot be determined until enough slough or eschar is removed to expose the base of the wound.
Ulcers do not progress through stages in formation or healing.
In a person with dark skin pigmentation, a stage I ulcer may appear as a persistent red, blue, or purple discoloration.
The presence of a pressure ulcer does not indicate that the patient does not have access to adequate services or support.
The Correct Answer is D
Choice A reason: This is correct. When slough or eschar obscures the wound bed, the ulcer is classified as unstageable until the base is visible. Accurate staging requires assessment of tissue depth and type.
Choice B reason: This is correct. Pressure ulcers do not progress through stages as they heal. For example, a stage 4 ulcer does not become a stage 3 ulcer during healing. Instead, it is described as a “healing stage 4 ulcer.”
Choice C reason: This is correct. In individuals with dark skin, early signs of pressure injury may present as persistent discoloration rather than visible redness. Recognizing these variations is essential for early detection.
Choice D reason: This is incorrect. The presence of a pressure ulcer may reflect inadequate care, poor mobility support, or lack of access to services. While not always indicative of neglect, it warrants evaluation of the patient’s support system and care environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The content of the voice (calling her name) does not determine whether the experience is psychotic. Psychotic hallucinations are typically persistent, intrusive, and occur during full wakefulness. Calling her name alone does not rule in or out psychosis.
Choice B reason: Hearing the voice of a close family member can occur in both psychotic and non-psychotic contexts. Bereavement-related hallucinations often involve familiar voices and are considered normal if they are transient and occur in specific emotional contexts.
Choice C reason: The absence of command hallucinations reduces the risk of harm but does not alone determine whether the experience is psychotic. Non-command hallucinations can still be part of psychosis if they are persistent and occur outside sleep transitions.
Choice D reason: Hypnagogic hallucinations—those occurring as one is falling asleep—are considered normal phenomena and not indicative of psychosis. In the context of recent bereavement and emotional triggers, this experience is consistent with a non-pathological grief response.
Correct Answer is C
Explanation
Choice A reason: Psoriasis vulgaris is the most common form of psoriasis and typically affects the scalp, elbows, knees, and lower back. While it can affect the trunk, it is more chronic and less likely to be triggered by a recent infection.
Choice B reason: Generalized pustular psoriasis is a severe and rare form of psoriasis that presents with widespread pustules and systemic symptoms such as fever and malaise. The boy’s presentation lacks pustules and systemic toxicity.
Choice C reason: Guttate psoriasis is characterized by small, drop-like erythematous plaques that often appear suddenly on the trunk and proximal extremities. It is commonly triggered by a recent group A Streptococcal infection, such as tonsillitis. This matches the boy’s history and clinical findings.
Choice D reason: Inverse psoriasis affects intertriginous areas such as the axillae, groin, and under the breasts. It presents with smooth, shiny lesions and is not typically triggered by streptococcal infections. The trunk distribution and recent tonsillitis make this diagnosis unlikely.
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