A person has a pressure ulcer on their coccyx, and the top layer of the skin is lost and looks like a blister. What pressure ulcer stage is this?
Stage 1
Stage 4
Stage 3
Stage 2
The Correct Answer is D
Choice A reason: Stage 1 pressure ulcers present with intact skin showing non-blanchable redness, typically over bony prominences, due to localized ischemia from sustained pressure. No skin loss or blistering occurs, as the epidermis remains intact, indicating early tissue stress without ulceration. This does not match the described blister and skin loss, making it incorrect.
Choice B reason: Stage 4 pressure ulcers involve full-thickness tissue loss, exposing underlying structures like muscle, bone, or tendons. Severe necrosis and deep tissue damage occur due to prolonged pressure, disrupting blood supply extensively. The described superficial skin loss with a blister does not involve such deep structures, ruling out Stage 4.
Choice C reason: Stage 3 pressure ulcers feature full-thickness skin loss, extending into subcutaneous tissue but not to muscle or bone. They may show undermining or tunneling due to tissue necrosis. The described blister with top-layer skin loss suggests partial-thickness damage, not deep enough for Stage 3, making this choice incorrect.
Choice D reason: Stage 2 pressure ulcers involve partial-thickness skin loss, affecting the epidermis and possibly dermis, often appearing as a shallow ulcer or fluid-filled blister. The blister and loss of the top skin layer described indicate damage beyond redness but not full-thickness, aligning perfectly with Stage 2 characteristics, making this the correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Excessive plasma proteins increase oncotic pressure, pulling fluid into the vascular space, reducing edema. Edema occurs with low plasma proteins (e.g., hypoalbuminemia), as in liver or kidney disease, which decreases oncotic pressure, causing fluid leakage, making this choice incorrect.
Choice B reason: Lymph node dysfunction impairs lymphatic drainage, leading to fluid accumulation in tissues, causing edema (lymphedema). The lymphatic system normally returns interstitial fluid to circulation, so its failure results in swelling, particularly in extremities, making this the correct cause of edema.
Choice C reason: Decreased capillary permeability reduces fluid leakage into tissues, preventing edema. Edema occurs with increased permeability, as in inflammation, allowing fluid to escape into the interstitial space, making this choice incorrect as it opposes the mechanism of edema formation.
Choice D reason: Decreased capillary hydrostatic pressure reduces the force pushing fluid out of capillaries, decreasing edema. Edema is caused by increased hydrostatic pressure, as in heart failure, which forces fluid into tissues, making this choice incorrect for causing edema.
Correct Answer is B
Explanation
Choice A reason: Acute infections are not defined by location but by rapid onset and severity. While some infections may be localized, the hallmark is their abrupt, intense presentation, resolving quickly with treatment or spontaneously, making this choice incomplete and incorrect for fully describing acute infections.
Choice B reason: Acute infections are characterized by rapid onset, severe symptoms, and short duration, typically resolving within days to weeks. This reflects the body’s immediate immune response to pathogens, causing intense but transient symptoms, such as fever or pain, making this the correct choice.
Choice C reason: Non-apparent, prolonged symptoms describe subclinical or chronic infections, not acute ones. Acute infections present with noticeable, severe symptoms that resolve quickly, not persisting asymptomatically, making this choice incorrect for the characteristics of acute infections.
Choice D reason: Less severe, prolonged symptoms describe chronic infections, like tuberculosis, not acute infections. Acute infections feature rapid, intense symptoms that resolve quickly, not mild symptoms over time, making this choice incorrect for describing acute infections.
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