A nurse is assessing a client with a skin condition. Which of the following describes the client’s condition?
Full thickness skin loss with visible bone.
Intact skin with localized erythema.
Partial-thickness skin loss with red tissue.
Full thickness skin loss with visible adipose tissue.
The Correct Answer is D
Choice A rationale
Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.
Choice B rationale
Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Choice C rationale
Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
Choice D rationale
Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.
Choice B rationale
Albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. Therefore, a nurse
should expect altered albumin levels in a client who reports anorexia and is experiencing malnutrition.
Choice C rationale
Total bilirubin is altered in clients who are experiencing hepatobiliary disease. It is not a laboratory test that supports a diagnosis of malnutrition.
Choice D rationale
Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.
Correct Answer is A
Explanation
Choice A rationale
Dehydration is a common finding in a patient who has had diarrhea for several days. Symptoms of dehydration can include dark-colored urine, excessive thirst, fatigue, dizziness, or light-headedness.
Choice B rationale
Diarrhea does not typically cause decreased bowel sounds.
Choice C rationale
A rigid abdomen is not a typical finding in a patient who has had diarrhea for several days.
Choice D rationale
Hypothermia is not a typical finding in a patient who has had diarrhea for several days.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.