A nurse is assessing a client who has a stage 2 pressure injury.
Which of the following findings should the nurse expect?
Full thickness skin loss with visible bone.
Intact skin with localized erythema.
Full thickness skin loss with visible adipose tissue.
Partial-thickness skin loss with red tissue in wound bed.
The Correct Answer is D
Choice A rationale:
Full thickness skin loss with visible bone. This choice does not align with the description of a stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness skin loss, but they do not involve visible bone. This description corresponds to a more severe stage of pressure injury.
Choice B rationale:
Intact skin with localized erythema. This choice describes a normal skin condition with localized redness (erythema) but does not indicate the presence of a pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, which means there is a break in the skin integrity.
Choice C rationale:
Full thickness skin loss with visible adipose tissue. This description is more in line with a stage 3 pressure injury, not a stage 2 injury. In stage 3, there is full-thickness skin loss, and adipose tissue may become visible in the wound bed. However, in stage 2, the skin loss is partial-thickness, and the wound bed typically contains red tissue.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed. This choice is the correct description of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss with the presence of red or pink tissue in the wound bed. It signifies damage to the epidermis and possibly the dermis. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Increasing the heat in the client's room is not the appropriate action for managing dyspnea. Dyspnea, or difficulty breathing, is not typically related to room temperature. Other interventions should be prioritized.
Choice B rationale:
Performing nasotracheal suctioning for the client is not the initial action to address dyspnea at the end of life. Suctioning is indicated when there is excessive secretions or airway obstruction but should not be the first intervention for dyspnea.
Choice C rationale:
Placing the head of the client's bed flat is not the best action for a client experiencing dyspnea. Elevating the head of the bed (Fowler's position) is the recommended position to improve lung expansion and reduce dyspnea in clients with breathing difficulties.
Choice D rationale:
Administering an opioid narcotic to the client is the most appropriate action for managing dyspnea at the end of life. Opioid medications, such as morphine, are often used to relieve severe dyspnea in hospice and palliative care settings. These medications can help relax the client and reduce the sensation of breathlessness. .
Correct Answer is A
Explanation
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