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 adipose tissue.
Intact skin with localized erythema.
Full-thickness skin loss with visible bone.
Partial-thickness skin loss with red tissue in the wound bed.
The Correct Answer is B
Choice A rationale:
Full-thickness skin loss with visible adipose tissue is not indicative of a stage 1 pressure injury. A stage 1 pressure injury involves intact skin with localized erythema. Full-thickness skin loss with visible adipose tissue is more characteristic of a stage 2 or higher pressure injury.
Choice B rationale:
Intact skin with localized erythema is the hallmark of a stage 1 pressure injury. In this stage, the skin is still intact, but there is non-blanchable erythema (redness) that indicates tissue damage. There is no full-thickness skin loss, and the underlying structures are not visible.
Choice C rationale:
Full-thickness skin loss with visible bone is not characteristic of a stage 1 pressure injury. This description is more in line with a stage 4 pressure injury, where there is extensive tissue loss, and bone or other underlying structures are visible.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed is not indicative of a stage 1 pressure injury. This description is more typical of a stage 2 pressure injury, where there is partial-thickness skin loss, but the wound bed may contain pink or red tissue without visible adipose tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Secondary prevention involves early detection and intervention to prevent the progression of a disease. In the case of breast cancer, a mammogram is a secondary prevention measure because it aims to detect cancer at an early stage, especially in individuals with a family history of the disease. Early detection can lead to timely treatment and improved outcomes.
Choice B rationale:
Echocardiograms are typically used to assess the function of the heart and diagnose existing heart conditions. While it is a valuable diagnostic tool, it is not an example of secondary prevention, which is focused on early detection and prevention of disease.
Choice C rationale:
Influenza vaccination is an example of primary prevention, as it aims to prevent the initial occurrence of the disease by providing immunity against the influenza virus. It is not considered a form of secondary prevention.
Choice D rationale:
Not scheduling a series of tests for an asymptomatic client does not fit the definition of secondary prevention. Secondary prevention involves screening and early detection in individuals at risk or with early signs of a disease to prevent its progression. An asymptomatic client without known risk factors may not require such testing as a preventive measure.
Correct Answer is A
Explanation
Choice A rationale:
Establishing whether the client's grieving is healthy or complicated is the first step in the nursing process when caring for a client experiencing grief. This step falls under the assessment phase of the nursing process and is essential for understanding the client's needs and planning appropriate care.
Choice B rationale:
Developing client-specific goals and outcomes comes after the assessment phase in the planning stage of the nursing process. While important, it is not the first action the nurse should take in this situation.
Choice C rationale:
Incorporating the treatment into the client's care occurs during the implementation phase of the nursing process and follows assessment and planning. This is not the first action.
Choice D rationale:
Determining whether coping strategies were successful is part of the evaluation phase of the nursing process, which occurs after the implementation of care. It is not the first step in this situation. Now, let's proceed to the final question.
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