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A nurse is collecting data on a client who has a stage 1 pressure injury.
Which of the following findings should the nurse expect?

Full thickness skin loss with visible adipose tissue.

Full thickness skin loss with visible bone.

Intact skin with localized erythema.

Partial-thickness skin loss with red tissue in the wound bed.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.

Choice B rationale:

Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.

Choice C rationale:

Stage 1 pressure injuries are characterized by intact skin with localized erythema.

Choice D rationale:

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.

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Correct Answer is C

Explanation

Choice A rationale:

There is probably a deeper injury than what appears on the surface is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice B rationale:

He has lain in one position for such a long time that swelling has occurred is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice C rationale:

Vessels have dilated and allowed plasma to leak into the wound site is the correct answer because this is a normal part of the inflammatory stage of wound healing.

Choice D rationale:

An infection is in progress at the wound site is incorrect because while swelling can be a sign of infection, it is also a normal part of the inflammatory stage of wound healing.

A. Decreased serum calcium. B. Decreased circulation. C. Increased collagen. D. Increased muscle mass.

Correct Answer is B

Explanation

Choice A rationale:

Decreased serum calcium does not directly contribute to pressure injury development.

Choice B rationale:

Decreased circulation can lead to tissue ischemia and necrosis, increasing the risk of pressure injury.

Choice C rationale:

Increased collagen is beneficial for wound healing and does not increase the risk of pressure injury.

Choice D rationale:

Increased muscle mass can actually provide more padding over bony prominences, reducing the risk of pressure injury.

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A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

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A nurse is collecting data on a client who has a stage 1 pressure injury.
Which of the following findings should the nurse expect?