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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Endotracheal intubation might be necessary in severe cases of respiratory depression, but it is not the first step in addressing opioid overdose.
B. Protamine sulfate is the antidote for heparin, not morphine.
C. Naloxone (Narcan) is an opioid antagonist that can rapidly reverse the effects of opioid overdose, including respiratory depression.
D. Administration of oxygen is supportive care but does not address the root cause of opioid overdose.
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