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 D
Explanation
Choice A reason: Facial trauma may increase aspiration risk if swallowing is impaired, but a 21-year-old typically has a robust immune system, reducing pneumonia risk. The trauma does not directly compromise lung defenses or immune function significantly, making this individual less likely to develop pneumonia compared to an immunocompromised person.
Choice B reason: Osteoarthritis and chronic knee pain in a 72-year-old may limit mobility, slightly increasing pneumonia risk due to reduced lung expansion. However, this condition does not directly impair immune function or lung clearance mechanisms, making it a lower risk compared to immunodeficiency, which severely predisposes to infections.
Choice C reason: Elevated cholesterol in a 48-year-old increases cardiovascular risk but does not directly affect lung function or immune response to infections. Without respiratory or immune compromise, this individual has a lower risk of pneumonia compared to someone with a primary immunodeficiency disorder, making this choice incorrect.
Choice D reason: A 69-year-old with a primary immunodeficiency disorder has a severely compromised immune system, impairing the ability to fight respiratory infections like pneumonia. Age-related lung changes and reduced immune response increase susceptibility to pathogens, making this individual at the highest risk for developing pneumonia, which is why this is correct.
Correct Answer is A
Explanation
Choice A reason: SIADH causes excessive antidiuretic hormone, leading to water retention and dilutional hyponatremia. Low serum sodium results from increased water reabsorption in the kidneys, causing neurological symptoms, making this the correct manifestation.
Choice B reason: Hyperkalemia is not associated with SIADH, which affects water balance, not potassium. Potassium imbalances occur in adrenal or renal disorders, not SIADH’s water retention mechanism, making this choice incorrect.
Choice C reason: Hyperglycemia is unrelated to SIADH, which involves water retention and sodium dilution. Glucose levels are affected by diabetes, not antidiuretic hormone dysfunction, making this choice incorrect for SIADH manifestations.
Choice D reason: Hypertension may occur in SIADH due to fluid overload, but it is not the primary manifestation. Hyponatremia is more specific, as water retention directly dilutes sodium, making this choice incorrect.
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