A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?
Stage I Pressure Ulcer
Stage II Pressure Ulcer
Stage IV Pressure Ulcer
Stage III Pressure Ulcer
The Correct Answer is B
Choice A rationale: Stage I pressure ulcers consist of non-blanching erythema with an intact epidermis unlike in the above picture.
Choice B rationale: This is correct since Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers as shown in the image above.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale: Bearing the weight of the body on the hands is not the correct technique for using crutches. The weight should be borne on the arms, not the hands.
Choice B rationale: Using crutches that belonged to someone else may not be appropriate as they need to be properly fitted for the individual. Additionally, old crutches may be worn or damaged.
Choice C rationale: This statement is appropriate and does not indicate a need for additional teaching. Keeping spare crutch tips is a good practice, as crutch tips can wear down over time and may need replacement. This demonstrates the client's understanding of the need for maintenance and preparedness.
Choice D rationale: This statement is appropriate and indicates a good understanding of crutch care. Regular inspection of crutches is important to ensure their safety and effectiveness. It allows the client to identify any signs of wear or damage early on and take necessary actions, such as replacing worn-out parts, to prevent accidents or injuries.
Correct Answer is D
Explanation
Choice A rationale: The stool test for occult blood is not primarily designed to detect bacteria.
Choice B rationale: Parasites are not typically detected through a stool test for occult blood.
Choice C rationale: Steatorrhea refers to the presence of excess fat in the stool and is not the primary focus of a stool test for occult blood.
Choice D rationale: The purpose of the stool test for occult blood is to check for the presence of blood in the stool, which may not be visible to the naked eye. This can be an indicator of gastrointestinal bleeding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today