The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of
Stage III
Stage II
Stage I
Stage IV
The Correct Answer is D
A. Stage III: This stage involves full-thickness tissue loss extending through the subcutaneous layer but does not typically present as a blister-like superficial wound.
B. Stage II: This stage is characterized by partial-thickness skin loss involving the epidermis and/or dermis, often presenting as a blister or superficial ulcer.
C. Stage I: Stage I pressure ulcers involve intact skin with non-blanchable redness, not a break in the skin or blister.
D. Stage IV: This stage involves full-thickness tissue loss with extensive destruction, potentially exposing bone or muscle, not a superficial blister.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 4+: This indicates very brisk reflexes with possible clonus, which is more than just brisk reflexes.
B. 2+: This indicates normal reflexes, not brisk.
C. 1+: This indicates diminished or hypoactive reflexes, not brisk.
D. 3+: This indicates brisk reflexes, which are faster than normal but without evidence of clonus.
Correct Answer is D
Explanation
A. Stage III: This stage involves full-thickness tissue loss extending through the subcutaneous layer but does not typically present as a blister-like superficial wound.
B. Stage II: This stage is characterized by partial-thickness skin loss involving the epidermis and/or dermis, often presenting as a blister or superficial ulcer.
C. Stage I: Stage I pressure ulcers involve intact skin with non-blanchable redness, not a break in the skin or blister.
D. Stage IV: This stage involves full-thickness tissue loss with extensive destruction, potentially exposing bone or muscle, not a superficial blister.
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