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 D
Explanation
Choice A rationale:
Piaget's formal operational stage is characterized by abstract thinking, hypothesis testing, and logical reasoning, but it does not include the development of object permanence. This stage typically occurs during adolescence, not in early childhood when object permanence is established.
Choice B rationale:
The preoperational stage is characterized by the development of symbolic thought and egocentrism but not object permanence. Object permanence starts to develop during the sensorimotor stage.
Choice C rationale:
Concrete operational thinking is focused on logical and systematic thinking related to concrete objects and events. It does not include the development of object permanence, which occurs in the earlier sensorimotor stage.
Choice D rationale:
Object permanence is a concept that develops during Piaget's sensorimotor stage, which typically occurs from birth to about two years of age. During this stage, children learn that objects continue to exist even when they are out of sight. They develop the ability to represent objects mentally and understand the concept of permanence.
Correct Answer is D
Explanation
Choice A rationale:
Fibromyalgia. Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain, fatigue, and tender points. It is not an example of acute pain. Acute pain typically has a sudden onset and is of limited duration.
Choice B rationale:
Peripheral neuropathy. Peripheral neuropathy can cause both acute and chronic pain, depending on the underlying cause. However, it is not a classic example of acute pain. Acute pain is usually associated with a specific injury or condition and has a sudden onset.
Choice C rationale:
Rheumatoid arthritis. Rheumatoid arthritis is a chronic autoimmune condition that can cause joint pain and inflammation. While it can have acute flares of pain, it is primarily considered a chronic condition. Acute pain typically results from injuries or conditions with a sudden onset.
Choice D rationale:
Surgical incision. This is the correct answer. A surgical incision represents a classic example of acute pain. It is a pain that results from a specific event, in this case, surgery, and typically has a well-defined onset and duration. Acute pain is often sharp and intense, and it resolves as the incision heals.
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