A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Full thickness skin loss with visible bone

Full thickness skin loss with visible adipose tissue.

Partial-thickness skin loss with red tissue in wound bed

Intact skin with localized erythema

Answer and Explanation

The Correct Answer is D

A. Full thickness skin loss with visible bone describes a stage 4 pressure injury.
B. Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury.
C. Partial-thickness skin loss with red tissue in the wound bed describes a stage 2 pressure injury.
D. Intact skin with localized erythema (redness) that does not blanch when pressure is applied is characteristic of a stage 1 pressure injury.

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Correct Answer is A

Explanation

A. Grilled salmon is high in protein and also provides omega-3 fatty acids, which are beneficial for wound healing.
B. Kidney beans are a good source of protein but not as high as salmon.
C. Raw spinach is nutritious but low in protein.
D. Peanut butter contains protein, but not as much as salmon and may not be as easily digestible for some patients.

A. Expression of concern about the presence of amenorrhea and breast atrophy. B. Refusal to eat. C. Refusal to exercise. D. Binge gorging with purging by vomiting.

Correct Answer is D

Explanation

A. Concerns about amenorrhea and breast atrophy are more commonly associated with anorexia nervosa.
B. Refusal to eat is more characteristic of anorexia nervosa.
C. Refusal to exercise is not typically associated with bulimia nervosa.
D. Binge gorging with purging by vomiting is a hallmark behavior of bulimia nervosa, where individuals consume large amounts of food and then attempt to eliminate the excess calories through purging methods such as vomiting.

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A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

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