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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 B

Explanation

Choice A rationale

5th ICS Left MCL is the location for the apical impulse (point of maximal impulse), not Erb's Point.

Choice B rationale

Erb's Point is located at the 3rd ICS Left SB and is significant for auscultation of heart sounds, particularly the S1 and S2 sounds.

Choice C rationale

2nd ICS Left SB is the location for auscultating the pulmonic valve area.

Choice D rationale

4th ICS Left SB is where the tricuspid valve is auscultated.

A. Visual acuity. B. Peripheral vision. C. Presence of the red reflex. D. Pupillary constriction to light.

Correct Answer is D

Explanation

Choice A rationale

Visual acuity tests assess the clarity of vision and the ability to discern letters or numbers at a set distance. It is used to test the function of cranial nerve II (optic nerve) rather than cranial nerve III (oculomotor nerve). Testing visual acuity involves using eye charts and assessing each eye separately.

Choice B rationale

Peripheral vision tests evaluate the ability to see objects outside the direct line of vision and are used to test the function of cranial nerve II (optic nerve). Peripheral vision assessment helps in diagnosing conditions like glaucoma but does not test the function of cranial nerve III.

Choice C rationale

The presence of the red reflex is assessed by looking into the eye with an ophthalmoscope to check for abnormalities in the eye's posterior segment. It is not related to the function of cranial nerve III but rather indicates healthy eye structures, including the retina and optic nerve (cranial nerve II).

Choice D rationale

Pupillary constriction to light is a direct test of cranial nerve III function. The oculomotor nerve controls the constriction of the pupil in response to light. By shining a light into the eyes and observing the pupils' response, the nurse can assess the integrity of cranial nerve III.

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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 instructor asks the student nurse to auscultate the client's Erb's Point. Where is the cardiac landmark referred to as the Erb's Point located?

Correct Answer is B

Explanation

When inspecting a patient's eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally.What other technique does a nurse use to test the function of this cranial nerve?

Correct Answer is D

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?