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 C
Explanation
Rationale:
When administering multiple liquid medications through an NG tube, it’s important to administer each medication separately to prevent drug interactions. After each medication, the NG tube should be flushed with 30 mL of water to ensure that the medication has been fully administered and to prevent the tube from becoming clogged.
Correct Answer is D
Explanation
Choice A rationale
Increased collagen is not a factor that would lead to a pressure injury in a client with impaired mobility. Collagen is a protein that helps in the formation of skin and other connective tissues.
Choice B rationale
Decreased serum calcium is not directly related to the development of pressure injuries. While calcium is important for bone health and muscle function, it does not play a direct role in skin integrity.
Choice C rationale
Increased muscle mass is not a risk factor for pressure injuries. In fact, good muscle mass can help distribute pressure more evenly and potentially reduce the risk of pressure injuries.
Choice D rationale
Decreased circulation is a major risk factor for the development of pressure injuries. When blood flow to an area of the body is reduced, the tissues in that area can become deprived of oxygen and nutrients, leading to cell death and the formation of pressure injuries.
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