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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: A stethoscope assesses heart sounds, detecting murmurs or irregular beats, but does not measure electrical conduction. It provides auditory data on valve function, not heart rate or rhythm via electrical activity. Electrocardiograms are required for detailed analysis of cardiac electrical patterns, making this choice incorrect.

Choice B reason: A blood pressure cuff measures arterial pressure, reflecting cardiovascular workload, but not electrical conduction. It provides systolic and diastolic values, not heart rhythm or rate data. Electrical activity assessment requires tools like electrocardiograms, rendering this choice irrelevant for the described diagnostic purpose.

Choice C reason: An electrocardiogram (ECG) records the heart’s electrical activity, mapping conduction pathways to assess heart rate and rhythm. It detects arrhythmias, ischemia, or conduction delays by analyzing waveforms like P, QRS, and T, making it the precise tool for evaluating cardiac electrical function, as required by the question.

Choice D reason: Doppler ultrasound evaluates blood flow velocity, used in vascular or fetal assessments, but does not measure cardiac electrical conduction. It lacks the capability to assess heart rate or rhythm through electrical signals, unlike an electrocardiogram, making it an incorrect choice for this diagnostic purpose.

A. Epidermis. B. Adipose tissue. C. Subcutaneous. D. Dermis.

Correct Answer is A

Explanation

Choice A reason: The epidermis is the most superficial skin layer, providing a protective barrier against pathogens and UV radiation. Composed of stratified squamous epithelium, it’s critical for skin integrity. Accurate identification guides wound care and assessments, ensuring proper management of superficial injuries or conditions like dermatitis in clinical practice.

Choice B reason: Adipose tissue is deep, within the subcutaneous layer, not superficial. The epidermis is the outermost layer. Misidentifying adipose risks misunderstanding skin anatomy, leading to errors in wound staging or treatment, potentially compromising care for superficial skin conditions requiring targeted interventions like topical therapies.

Choice C reason: The subcutaneous layer lies beneath the dermis, not superficially. The epidermis is the outermost layer. Assuming subcutaneous is superficial misguides skin assessments, risking incorrect wound care or misdiagnosis of skin conditions, critical for accurate treatment and prevention of complications in integumentary health.

Choice D reason: The dermis lies below the epidermis, containing blood vessels and nerves, not the most superficial layer. Misidentifying dermis risks errors in assessing skin injuries or conditions, potentially leading to inappropriate treatments. Recognizing the epidermis ensures proper care for superficial issues like burns or abrasions in clinical settings.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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