A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Partial-thickness skin loss.

Necrotic subcutaneous tissue.

Blood-filled blisters.

Exposed bone.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Necrotic subcutaneous tissue.

Choice A rationale:

Partial-thickness skin loss (Choice A) is characteristic of a stage II pressure ulcer, not a stage III ulcer. A stage II pressure ulcer involves the loss of the epidermis and possibly the dermis, resulting in a shallow open ulcer with a red-pink wound bed.

Choice B rationale:

Necrotic subcutaneous tissue is a manifestation of a stage III pressure ulcer. A stage III ulcer involves full-thickness skin loss where subcutaneous fat may be visible, but exposed bone or muscle is not yet present. Necrotic tissue in the wound bed indicates a more advanced level of tissue damage and the need for appropriate wound care to promote healing.

Choice C rationale:

Blood-filled blisters (Choice C) are not specific to pressure ulcers and are more commonly associated with friction or shear forces. These blisters are not indicative of a stage III pressure ulcer, which involves visible full-thickness tissue loss.

Choice D rationale:

Exposed bone (Choice D) is a characteristic of a stage IV pressure ulcer, not a stage III ulcer. A stage IV ulcer involves extensive tissue loss with exposure of muscle, tendon, or bone. This represents a severe level of tissue damage and requires intensive wound care and management.

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Correct Answer is D

Explanation

Choice A rationale:

Decreased heart rate is not an anticipated finding in response to acute pain. Pain typically triggers sympathetic nervous system activation, leading to an increased heart rate as a physiological response to the stressor.

Choice B rationale:

Hyperactive bowel sounds are not typically associated with acute pain. Acute pain is more likely to induce a sympathetic response, which can lead to decreased gastrointestinal motility and hypoactive bowel sounds.

Choice C rationale:

Decreased blood pressure is not a common response to acute pain. Pain often leads to an increase in blood pressure due to the activation of the sympathetic nervous system and the release of stress hormones.

Choice D rationale:

Increased respiratory rate is the anticipated finding in response to acute pain. Acute pain can cause an increase in the sympathetic nervous system activity, leading to a higher respiratory rate as the body prepares for a fight-or-flight response. This increased respiratory rate helps oxygenate the blood and meet the potential increased demand for energy during stress.

A. Respiratory rate. B. Temperature. C. Pulse rate. D. BP.

Correct Answer is B

Explanation

Choice A rationale:

Re-measuring the respiratory rate is unnecessary. The reported respiratory rate falls within the normal range of 12-20 breaths per minute for adults.

Choice B rationale:

Re-measuring the temperature is the correct action. Tympanic temperature measurements can be influenced by factors such as earwax buildup, ear infection, or improper placement of the thermometer. Repeating the temperature measurement ensures accuracy.

Choice C rationale:

Re-measuring the pulse rate is unnecessary. The reported pulse rate of 92 beats per minute falls within the normal range of 60-100 beats per minute for adults.

Choice D rationale:

Re-measuring the blood pressure is unnecessary. The reported blood pressure of 88/58 mm Hg, while at the lower end of the normal range (typically around 90/60 mm Hg), is not excessively low and doesn't indicate an immediate need for concern.

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A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

Correct Answer is D

Explanation

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Correct Answer is B

Explanation

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