A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

Full-thickness skin loss with visible bone.

Full-thickness skin loss with visible adipose tissue.

Skin remains intact 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 bone is characteristic of a stage 4 pressure injury, not a stage 1 pressure injury.

Choice B rationale

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

Choice C rationale

In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Choice D rationale

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

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Correct Answer is D

Explanation

Choice A rationale

Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue.

Choice B rationale

A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing.

Choice C rationale

Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing.

Choice D rationale

In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.

A. Dehydration B. Decreased bowel sounds C. Rigid abdomen D. Hypothermia

Correct Answer is A

Explanation

Choice A rationale

Dehydration is a common finding in a patient who has had diarrhea for several days. Symptoms of dehydration can include dark-colored urine, excessive thirst, fatigue, dizziness, or light-headedness.

Choice B rationale

Diarrhea does not typically cause decreased bowel sounds.

Choice C rationale

A rigid abdomen is not a typical finding in a patient who has had diarrhea for several days.

Choice D rationale

Hypothermia is not a typical finding in a patient who has had diarrhea for several days.

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A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient who has a wound that is healing by first intention. What findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assessing a patient who has had diarrhea for several days. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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