In a patient’s chart, it notes that the patient has a stage 1 pressure injury. Which of the following findings would you expect to see when you do your assessment?
Full thickness skin loss with visible bone.
Intact skin with localized erythema.
Full thickness skin loss with visible adipose tissue.
Partial-thickness skin loss with red tissue in wound bed.
The Correct Answer is B
Choice A reason: Full thickness skin loss with visible bone indicates a stage 4 pressure injury, not stage 1, which involves intact skin with erythema. Misidentifying this overstates severity, risking inappropriate interventions like surgical debridement instead of preventive measures like repositioning, critical for managing early-stage pressure injuries to prevent progression.
Choice B reason: Stage 1 pressure injury presents as intact skin with non-blanchable localized erythema, often over bony prominences, due to early tissue compression. This finding guides preventive care, like pressure relief and skin protection, to halt progression. Accurate identification ensures timely interventions, reducing risk of deeper tissue damage in at-risk patients.
Choice C reason: Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury, not stage 1, which has intact skin. Assuming this misdiagnoses severity, leading to unnecessary aggressive treatments like wound dressings, while neglecting early interventions like offloading pressure, critical for preventing worsening of stage 1 injuries.
Choice D reason: Partial-thickness skin loss with red tissue indicates a stage 2 pressure injury, not stage 1, which shows intact skin with erythema. Misidentifying this risks inappropriate wound care, delaying preventive strategies like skin moisturizing or repositioning, essential for managing stage 1 injuries and preventing progression to deeper ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Taking retirement checks and limiting access to funds is financial abuse, exploiting the patient’s resources. This violates elder rights, requiring reporting and social service intervention. Accurate identification ensures protection, critical for restoring financial autonomy and preventing further exploitation, enhancing safety and well-being in vulnerable elderly patients.
Choice B reason: Emotional abuse involves psychological harm like humiliation, not directly indicated by taking retirement funds, which is financial abuse. Assuming emotional risks misclassification, delaying financial protection measures, critical for addressing exploitation and ensuring the patient’s economic security, essential for elder abuse prevention and support.
Choice C reason: Neglect involves failure to provide care, like food or medical needs, not specifically taking funds, which is financial abuse. Misidentifying as neglect risks overlooking financial exploitation, delaying interventions like legal guardianship, critical for protecting the patient’s assets and ensuring safety in elder care settings.
Choice D reason: Physical abuse involves bodily harm, not indicated by financial exploitation like taking retirement checks. Assuming physical risks missing financial abuse, delaying reporting or social services, critical for stopping exploitation, restoring financial control, and ensuring the patient’s safety and dignity in elder abuse scenarios.
Correct Answer is D
Explanation
Choice A reason: Urinary retention involves inability to empty the bladder, causing overflow, not involuntary leakage during laughing or sneezing, which indicates stress incontinence. Misdiagnosing retention risks inappropriate treatments like catheterization, delaying pelvic exercises or medications, critical for managing stress incontinence and improving quality of life in affected patients.
Choice B reason: Constipation affects bowel function, not urinary control, unlike stress incontinence, where leakage occurs during physical stress like sneezing. Assuming constipation misguides diagnosis, risking neglect of urinary interventions like Kegel exercises, essential for strengthening pelvic muscles and preventing incontinence-related limitations in daily activities.
Choice C reason: Hiatal hernia causes gastrointestinal symptoms like reflux, not urinary leakage during activities, which defines stress incontinence. Misdiagnosing hernia risks overlooking pelvic floor issues, delaying treatments like biofeedback, critical for managing incontinence, reducing activity limitations, and improving comfort in patients with stress-related urine loss.
Choice D reason: Stress incontinence involves involuntary urine leakage during activities like laughing or sneezing due to weakened pelvic floor muscles, common in women. Recognizing this guides interventions like pelvic exercises or surgery, critical for reducing activity limitations, improving quality of life, and addressing physical and emotional impacts in affected patients.
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