A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
Intact skin with localized erythema.
Full thickness skin loss with visible bone
Full thickness skin loss with visible adipose tissue.
Partial-thickness skin loss with red tissue in wound bed.
The Correct Answer is D
A. Intact skin with localized erythema:
Explanation: This description is more consistent with a stage 1 pressure injury, where there is non-blanchable erythema.
B. Full thickness skin loss with visible bone:
Explanation: This description is more consistent with a stage 4 pressure injury, which involves extensive tissue loss, including exposure of bone.
C. Full thickness skin loss with visible adipose tissue:
Explanation: This finding is characteristic of a stage 3 pressure injury, where the loss of tissue extends down to the subcutaneous layer.
D. Partial-thickness skin loss with red tissue in the wound bed:
Explanation: This description is consistent with a stage 2 pressure injury, where there is partial-thickness skin loss involving the epidermis and possibly the dermis, forming a shallow open ulcer with a red-pink wound bed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 8.0: An aspirate pH of 8.0 would indicate an alkaline substance. This would not be typical of stomach contents, which are acidic. An alkaline pH might suggest placement in the intestines or respiratory tract.
B. 6.0: While this is less alkaline than 8.0, it is still not within the typical range for stomach contents. Stomach aspirate is generally more acidic.
C. 7.0: A pH of 7.0 is neutral. Stomach contents are typically more acidic, so a neutral pH would not be consistent with correct NG tube placement in the stomach.
D. 4.0: This is within the acidic range and is consistent with the pH of stomach contents. It would be considered an indication of correct NG tube placement in the stomach.
Correct Answer is A
Explanation
A. Constipation
This is correct. Inadequate dietary intake of fiber can lead to constipation. Fiber adds bulk to the stool and promotes regular bowel movements.
B. Memory loss
Memory loss is not typically associated with an inadequate dietary intake of fiber. It is more commonly related to other factors such as aging, medical conditions, or nutritional deficiencies.
C. Brittle hair
Brittle hair is not a direct result of an inadequate intake of dietary fiber. Hair health is influenced by various factors, including overall nutrition and hydration.
D. Bleeding gums
Bleeding gums are not directly linked to an inadequate intake of fiber. However, insufficient vitamin C intake, which is often found in fruits and vegetables (sources of fiber), can contribute to gum problems.
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