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:
Holding the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating is not the best practice for wound irrigation. It's crucial to maintain a close distance to the wound to ensure that the irrigation solution effectively cleans the area.
Choice B rationale:
Chilling the irrigant prior to the procedure is not necessary and could be uncomfortable for the patient. Room temperature or slightly warmed sterile saline solution is typically used for wound irrigation to prevent temperature-related discomfort.
Choice C rationale:
Flushing the wound from the most contaminated area to the cleanest area is an incorrect approach for wound irrigation. The wound should be irrigated from the cleanest to the most contaminatedto prevent contamination of previously clean areas and ensures thorough cleaning of the wound.
Choice D rationale:
Irrigating the wound until the solution that is draining is clear is a common practice for wound irrigation. It indicates that the wound is free of contaminants, debris, and infectious material.
Correct Answer is D
Explanation
Choice A rationale:
Spirituality can increase feelings of hopelessness. This statement is not accurate. In many cases, spirituality can provide comfort, support, and a sense of hope for individuals who are nearing the end of life. Many people turn to their faith and spirituality as a source of strength and consolation during difficult times.
Choice B rationale:
Spirituality can increase the desire to hasten death. This statement is not generally true. Spirituality often has the opposite effect by providing a sense of purpose and meaning in life, which can help individuals find reasons to continue living. While some individuals may grapple with complex feelings related to death, it's not a typical outcome of embracing spirituality.
Choice C rationale:
Spirituality can increase depression. This statement is not accurate. Spirituality can actually serve as a source of emotional support and resilience for individuals facing the end of life. It can help individuals cope with their emotions and provide a sense of peace and comfort.
Choice D rationale:
Spirituality can increase the quality of life. This statement is correct. Spirituality often plays a positive role in the lives of individuals nearing the end of life. It can enhance the quality of life by providing emotional and psychological support, promoting a sense of purpose, and helping individuals find comfort and peace during this challenging time.
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