A nurse is attending to a patient who is unable to move.
Which stage of pressure injuries is most likely indicated by the presence of non-blanchable erythema on the patient’s heels?
Stage I pressure injury.
Stage II pressure injury.
Stage III pressure injury.
Stage IV pressure injury.
The Correct Answer is A
Choice A rationale
Stage I pressure injury is characterized by non-blanchable erythema of intact skin. This means that the skin does not turn white when pressed and is a sign of damage to the underlying
tissues. This stage is often seen in areas of the body that are under constant pressure, such as the heels in a patient who is unable to move.
Choice B rationale
Stage II pressure injury involves partial-thickness loss of skin with exposed dermis. This stage is more severe than stage I and would present with an open wound, which is not described in the question.
Choice C rationale
Stage III pressure injury involves full-thickness loss of skin, in which fatty tissue is visible in the wound. This stage is more severe than both stages I and II and would present with a deeper wound, which is not described in the question.
Choice D rationale
Stage IV pressure injury involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. This is the most severe stage of pressure injury and would present with a very deep wound exposing underlying structures, which is not described in the question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
After a total laryngectomy, patients may have difficulty swallowing fluids due to changes in the anatomy of the throat.
Choice B rationale
It is not accurate to say that it is no longer possible for the patient to choke on or aspirate food after a total laryngectomy. While the risk of aspiration is reduced because the airway and digestive tract are separated, the patient can still experience choking on food if it is not properly swallowed.
Choice C rationale
Adding a thickener to liquids can help prevent aspiration, but this is typically more relevant for patients with dysphagia or other swallowing disorders, not specifically for patients post- laryngectomy.
Choice D rationale
Tucking the chin when swallowing, also known as the chin-tuck maneuver, can help prevent aspiration by narrowing the entrance to the airway. This can be a useful technique for patients after a laryngectomy.
Correct Answer is A
Explanation
Choice A rationale
Finasteride, a medication used to treat benign prostatic hypertrophy, can cause several side effects, including a decrease in libido or sexual desire.
Choice B rationale
There’s no specific interaction between finasteride and grapefruit juice. Therefore, patients don’t need to avoid grapefruit juice when taking this medication.
Choice C rationale
Finasteride can actually cause a decrease in PSA (prostate-specific antigen) levels. If a patient is having a PSA test, they should tell their doctor they are taking finasteride because it can affect the results.
Choice D rationale
It may take up to six months or more to see the full effects of finasteride. Therefore, patients should not expect to see a response within one week.
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