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 D
Explanation
Choice A reason: Swallowing water tests cranial nerves IX and X, not XI (spinal accessory), which controls trapezius and sternocleidomastoid muscles. Shoulder shrugging tests XI. Misidentifying this risks incorrect neurological assessment, potentially missing deficits in motor function, critical for diagnosing conditions affecting cranial nerve XI in clinical evaluations.
Choice B reason: Saying “light, tight, dynamite” tests cranial nerve XII (hypoglossal) for tongue movement, not XI, which involves shoulder and neck muscles. Assuming this assesses XI misguides neurological evaluation, risking oversight of motor weaknesses, essential for accurate diagnosis and management of cranial nerve-related disorders in patients.
Choice C reason: Identifying a smell tests cranial nerve I (olfactory), not XI, which governs shoulder and neck movements. Misidentifying this risks incorrect cranial nerve assessment, potentially missing motor deficits in XI, critical for diagnosing neurological conditions like nerve injuries or tumors affecting shoulder and neck function.
Choice D reason: Shrugging shoulders and turning the head against resistance tests cranial nerve XI (spinal accessory), assessing trapezius and sternocleidomastoid strength. This ensures accurate neurological evaluation, detecting deficits from nerve damage or lesions, guiding diagnosis and treatment, critical for managing motor function in patients with suspected cranial nerve issues.
Correct Answer is C
Explanation
Choice A reason: Full range of motion against gravity only corresponds to a 3/5 muscle strength rating, indicating the muscle can move the joint against gravity but not additional resistance. This is weaker than 4/5, which includes some resistance, making this choice incorrect for the described strength level.
Choice B reason: Visible muscle contraction without joint movement indicates a 1/5 rating, reflecting minimal strength, often seen in severe neurological or muscular disorders. This is far below a 4/5 rating, which requires full range of motion and resistance, making this choice irrelevant to the question.
Choice C reason: A 4/5 muscle strength rating indicates full range of motion against gravity with some resistance, but not maximal. This reflects good muscle function, slightly below normal, often due to minor injury or fatigue. It aligns with standard muscle strength scales, making it the correct choice.
Choice D reason: Full range of motion against gravity with full resistance corresponds to a 5/5 rating, indicating normal muscle strength. This is stronger than 4/5, which involves only some resistance, reflecting a slight deficit. This choice does not match the described strength level.
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