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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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Lordosis refers to an excessive inward curvature of the lumbar spine, often referred to as swayback. This condition causes the lower back to arch more than normal, leading to a prominent abdomen and buttocks. Lordosis does not affect the thoracic spine and does not cause an exaggerated curvature in that region.

Choice B rationale

Scoliosis is a lateral curvature of the spine that results in an S- or C-shaped curve. It can occur in the thoracic, lumbar, or cervical regions of the spine. Scoliosis involves a sideways deviation rather than an exaggerated curvature in the thoracic spine.

Choice C rationale

Spinal dysplasia is a broad term that refers to various congenital abnormalities affecting the development of the spine. It includes conditions such as spina bifida, kyphosis, and scoliosis, each with distinct characteristics. The term itself does not specify an exaggerated thoracic curvature.

Choice D rationale

Kyphosis is an exaggerated outward curvature of the thoracic spine, resulting in a rounded or hunched back appearance. This condition is common in elderly individuals and can be caused by factors such as osteoporosis, vertebral fractures, or degenerative changes. It leads to a noticeable forward bend of the upper back.

A. The nurse will understand the unaffected ear will show lateralization to the Weber's test. B. Place the activated tuning fork to the mid skull and ask if the patient can hear it louder in either ear. C. Place the activated tuning fork to the patient's mastoid bone first then place over air. D. Place the activated tuning fork to the client's ear over the mastoid bone then activate it again over the air.

Correct Answer is B

Explanation

Choice A rationale

Lateralization to the unaffected ear in Weber's test actually indicates sensorineural hearing loss in the affected ear. This choice is incorrect as it doesn’t describe the correct procedure for the test.

Choice B rationale

The Weber's test involves placing an activated tuning fork in the midline of the skull and asking the patient if the sound is heard more loudly in either ear. This helps determine if there is lateralization, which is key in diagnosing the type of hearing loss. Thus, this is the correct procedure for the test.

Choice C rationale

Placing the tuning fork on the mastoid bone and then over air is actually part of the Rinne test, not the Weber test. This choice is, therefore, incorrect for the Weber test.

Choice D rationale

Similar to Choice C, this process describes the Rinne test, which compares air conduction and bone conduction of sound. This is not the correct method for performing Weber’s test.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is examining an elderly client and notes an exaggerated curvature of the thoracic spine.The nurse should document this finding as which of the following?

Correct Answer is D

Explanation

The nurse plans to assess the client's hearing.What action should the nurse take when performing the Weber's test?

Correct Answer is B

Explanation

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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?

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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?