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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 B

Explanation

Choice A rationale:

Increased pallor of the surgical site is not a typical sign of wound dehiscence. It could indicate poor blood flow to the area, but it’s not directly related to dehiscence.

Choice B rationale:

Increased serosanguineous drainage from the wound is a common sign of wound dehiscence. This type of drainage is a mixture of blood and serum, and an increase could indicate that the wound edges are separating.

Choice C rationale:

Excessive gas is not a typical sign of wound dehiscence. It could be related to other postoperative complications, such as ileus or bowel obstruction, but not specifically to dehiscence.

Choice D rationale:

Complaint of constipation is not a typical sign of wound dehiscence. It could be related to other postoperative complications, such as side effects of pain medication or decreased mobility, but not specifically to dehiscence.

A. Laceration. B. Contusion. C. Keloid. D. Hematoma.

Correct Answer is C

Explanation

Choice A rationale:

A laceration is a cut or tear in the skin, not a raised scar.

Choice B rationale:

A contusion is a bruise caused by an impact to the skin, not a raised scar.

Choice C rationale:

A keloid is a thick, raised scar that can develop at the site of an injury or inflammation. It’s more common in people with darker skin tones.

Choice D rationale:

A hematoma is a collection of blood outside of the blood vessels, not a raised scar.

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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?