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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The correct answer is choicea. Increase daily caloric intake by 300 to 400 calories,b. Consume folic acid supplements daily, andd. Take daily iron and calcium supplements.
Choice A rationale:
Pregnant teenagers need to increase their daily caloric intake by 300 to 400 calories to support the growth and development of the fetus.
Choice B rationale:
Folic acid is crucial for preventing neural tube defects in the developing fetus.Daily supplementation is recommended.
Choice C rationale:
Pregnant teenagers need to increase their protein intake to support fetal growth and maternal health.Maintaining current protein intake is not sufficient.
Choice D rationale:
Iron and calcium are essential for the development of the fetus and the health of the mother.Daily supplementation helps prevent deficiencies.
Choice E rationale:
Limiting weight gain to no more than 15 pounds is not recommended.Healthy weight gain during pregnancy varies but is generally higher than 15 pounds to support fetal development.
Correct Answer is C
Explanation
Choice A rationale
Vibration of the eardrum is not directly transmitted to the eighth cranial nerve, bypassing the inner ear structures. The vibrations from the eardrum are first transmitted through the ossicles (tiny bones in the middle ear) to the cochlea in the inner ear.
Choice B rationale
Sound waves enter the ear canal, but they are not directly converted to electrical impulses. The sound waves cause the eardrum to vibrate, and these vibrations are transmitted through the ossicles to the cochlea, where they are converted into electrical signals that are sent to the brain via the eighth cranial nerve.
Choice C rationale
Vibration of the eardrum transmits through the bony ossicles to the perilymph in the inner ear, stimulating the eighth cranial nerve. This is the correct description of the process of hearing.
Choice D rationale
Sound is not transmitted directly from the eardrum to the brain. The sound-induced vibrations of the eardrum are transmitted through the ossicles to the cochlea, where they are converted into electrical signals that are sent to the brain via the eighth cranial nerve.
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