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: Photophobia, sensitivity to light, is not associated with hypothyroidism. It occurs in conditions like migraines or meningitis. Hypothyroidism slows metabolism, causing fatigue, not light sensitivity, making this choice incorrect.
Choice B reason: Exophthalmos, protruding eyes, is associated with hyperthyroidism (Graves’ disease) due to orbital inflammation. Hypothyroidism does not cause eye protrusion, making this choice incorrect for hypothyroidism manifestations.
Choice C reason: Weight loss is typical of hyperthyroidism due to increased metabolism. Hypothyroidism slows metabolism, causing weight gain, not loss, due to reduced energy expenditure, making this choice incorrect.
Choice D reason: Hypothyroidism reduces thyroid hormone levels, slowing metabolism and causing lethargy, fatigue, and reduced energy. This is a hallmark symptom due to decreased cellular activity, making this the correct choice.
Correct Answer is D
Explanation
Choice A reason: Type 2 diabetes involves insulin resistance, not excessive insulin production, which declines over time. Insulin does not cause renal toxicity; hyperglycemia damages kidneys, making this choice incorrect for the mechanism of renal failure.
Choice B reason: Glucose crystals do not form in type 2 diabetes to obstruct ureters. Hyperglycemia damages renal vasculature, not urine flow, leading to diabetic nephropathy, making this choice incorrect for chronic renal failure’s mechanism.
Choice C reason: An autoimmune process destroying renal tissue is not typical of type 2 diabetes. Autoimmune damage occurs in type 1 diabetes or glomerulonephritis, not type 2-related renal failure, making this choice incorrect.
Choice D reason: High blood sugar in type 2 diabetes damages renal microvasculature, particularly glomerular capillaries, causing diabetic nephropathy. This leads to proteinuria, glomerulosclerosis, and chronic renal failure, making this the correct mechanism for kidney damage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.