A patient has been admitted to the hospital after the staff at a nursing home noticed a pressure ulcer on his sacral area.
The nurse examines the sacral ulcer and determines it is a Stage II ulcer.
Which of these findings is characteristic of a Stage II pressure ulcer?
Patches of eschar cover parts of the wound.
Partial thickness skin erosion is observed with a loss of dermis and epidermis.
Ulcer extends into the subcutaneous tissue.
Intact skin appears red but not broken.
Open blister areas have a red-pink wound bed.
Localized redness in light skin will blanch with fingertip pressure.
Correct Answer : B,E
Choice A rationale
Patches of eschar covering parts of the wound are characteristic of more advanced pressure ulcers, such as Stage III or IV, where necrotic tissue is present. Eschar is a dark, thick, leathery scab or crust that indicates deeper tissue damage and is not observed in Stage II pressure ulcers.
Choice B rationale
A Stage II pressure ulcer is characterized by partial thickness skin erosion with loss of the epidermis and dermis. It appears as a shallow open ulcer with a red-pink wound bed, indicating that the damage has not extended beyond these layers of skin.
Choice C rationale
When a pressure ulcer extends into the subcutaneous tissue, it is classified as a Stage III or IV ulcer, depending on the depth and extent of tissue involvement. Stage II ulcers are limited to the epidermis and dermis and do not reach the subcutaneous layer.
Choice D rationale
Intact skin that appears red but is not broken is indicative of a Stage I pressure ulcer, which represents the earliest stage of pressure injury. Stage I ulcers involve non-blanchable erythema (redness) but no open wound or skin erosion.
Choice E rationale
Open blister areas with a red-pink wound bed are characteristic of Stage II pressure ulcers. These ulcers exhibit partial thickness skin loss and can present as open or fluid-filled blisters with a visible wound bed.
Choice F rationale
Localized redness in light skin that blanches with fingertip pressure is typical of a Stage I pressure ulcer. Blanching erythema indicates that the skin is still viable and blood flow is present, which differentiates Stage I from more advanced stages of pressure injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Fibrocystic lesions in the breast are benign changes that involve the formation of cysts and fibrous tissue. These do not typically cause an orange-peel appearance of the skin.
Choice B rationale
A normal finding of the breast would not include an orange-peel or "peau d'orange" appearance, as this is considered an abnormal change often associated with underlying pathology.
Choice C rationale
Carcinoma of the breast can lead to an orange-peel appearance of the skin due to lymphatic obstruction. This dimpling effect is caused by the cancerous infiltration and thickening of the skin, making this the correct answer.
Choice D rationale
Fibroadenoma is a benign tumor of the breast and does not usually cause the skin changes described as orange-peel appearance. This condition is generally not associated with skin texture changes.
Correct Answer is A
Explanation
Choice A rationale
Without treatment, glaucoma can lead to blindness due to the progressive damage it causes to the optic nerve. Elevated intraocular pressure damages the optic nerve fibers, leading to peripheral vision loss and eventually total blindness if untreated.
Choice B rationale
Double vision is not a common symptom of glaucoma. Instead, glaucoma typically presents with symptoms like gradual peripheral vision loss, eye pain, and halos around lights.
Choice C rationale
Glaucoma is primarily caused by increased intraocular pressure, either due to overproduction of aqueous humor or improper drainage, not inadequate fluid production.
Choice D rationale
Use of eye drops helps to control intraocular pressure but does not improve vision; it helps to prevent further damage to the optic nerve.
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