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
Explanation
Choice A rationale: Overflow incontinence is characterized by a constant leakage of small amounts of urine and a distended, palpable bladder due to incomplete emptying. This is consistent with the client's symptoms.
Choice B rationale: Reflex incontinence is associated with neurologic dysfunction but does not typically involve constant leakage.
Choice C rationale: Stress incontinence is associated with increased intra-abdominal pressure and typically involves leakage with activities like coughing or sneezing.
Choice D rationale: Urge incontinence is characterized by a sudden, strong urge to void and is not typically associated with constant leakage.
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.
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