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 ["A","D","E"]
Explanation
A. Immobility can lead to pressure ulcers due to prolonged pressure on bony prominences.
B. Polyuria is not a common complication of immobility.
C. Diarrhea is not typically associated with immobility; constipation is more common.
D. Immobility can cause contractures of the extremities due to muscle shortening and tightening.
E. Crackles in the lungs can occur due to fluid accumulation and reduced lung expansion associated with immobility.
Correct Answer is D
Explanation
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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