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 B
Explanation
Choice A rationale:
Increased sensitivity to touch is not typically an age-related change in older adults. In fact, older adults often experience a decrease in sensitivity due to factors like reduced skin elasticity and changes in nerve function.
Choice C rationale:
Increased peripheral vision is not a common age-related change. Visual changes in older adults usually involve decreased visual acuity, difficulties with night vision, and increased sensitivity to glare.
Choice D rationale:
An increase in the size of pupils is not an expected age-related change. Pupils may become smaller and react more sluggishly to changes in light in older adults, but a consistent increase in pupil size is not a common finding.
Choice B rationale:
An increase in cerumen in the ear canal is a common age-related change. Cerumen, or earwax, can accumulate more in older adults due to changes in the composition of earwax and slower migration of earwax out of the ear canal. It can lead to hearing difficulties and may need management. Moving on to the last question.
Correct Answer is A
Explanation
Choice A rationale:
The CDC and other health organizations recommend at least 150 minutes of moderate-intensity aerobic exercise per week for overall health, which includes benefits for bone health. Weight-bearing exercises are particularly important for preventing osteoporosis.
Choice B rationale:
Performing vigorous exercise at least 2 times per week is generally recommended for maintaining cardiovascular health and overall fitness. However, for a client at risk for osteoporosis, the primary focus should be on calcium and vitamin D intake to support bone health and density. Vigorous exercise alone may not provide the necessary nutrients for bone health.
Choice C rationale:
Taking 400 IU of vitamin D supplement each day is a reasonable recommendation to support bone health, as vitamin D is essential for calcium absorption. However, the primary concern for a client at risk for osteoporosis is calcium intake. While vitamin D is important, calcium supplementation is more critical for addressing this specific issue.
Choice D rationale:
The RDA for calcium is generally 1,000 mg for adults up to age 50 and 1,200 mg for women over 50 and men over 70. For someone at risk of osteoporosis, ensuring adequate calcium intake is essential for bone health.
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