The nurse is admitting a client to the medical-surgical unit and notes the skin breakdown shown in the diagram. How should the nurse document the finding?

Stage III

unstageable

necrotic stage I

stage II

Answer and Explanation

The Correct Answer is B

A.   Stage III pressure ulcers are characterized by full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue.
B.   The above image depicts an Unstageable pressure ulcers since the base of the ulcer is covered by slough in the wound bed.
C.   The term 'necrotic stage I' is not typically used in the staging of pressure ulcers. Necrosis refers to dead tissue, which is not present in a Stage I pressure ulcer. Stage I ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

D. Stage II pressure ulcers involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed or as an intact or ruptured blister. The ulcer is painful and may appear as a shiny or dry shallow ulcer without slough or bruising.

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Correct Answer is A

Explanation

A. In a trauma situation, airway, breathing, and circulation (ABCs) are the top priority. Evaluating chest expansion assesses the client’s ability to breathe and maintain oxygenation, making it the first action.

B. Checking the client's orientation is important but secondary to assessing breathing.

C. Pupillary response is an assessment that is important but comes after ensuring the client is breathing adequately.

D. Capillary refill are assessments that are important but come after ensuring the client is breathing adequately.

Correct Answer is {"dropdown-group-1":"F","dropdown-group-2":"D"}

Explanation

The client's symptoms of profuse sweating, irritability, weight loss, heat intolerance, and bulging eyes are indicative of hyperthyroidism, possibly from Graves' disease. Hyperthyroidism speeds up metabolism, leading to the described symptoms, including increased heart rate.

Continuous telemetry is appropriate for monitoring the heart, as the client is experiencing sinus tachycardia, which is a common finding in hyperthyroidism.

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The nurse is admitting a client to the medical-surgical unit and notes the skin breakdown shown in the diagram. How should the nurse document the finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in the trauma unit has received a report on a client who has multiple injuries as a result of a motor vehicle crash. Which action should the nurse plan to take first?

Correct Answer is A

Explanation

Select the words from the choices below to fill in each blank in the sentences. The client is most likely exhibiting dropdown . dropdown .is an appropriate nursing intervention.

Correct Answer is {"dropdown-group-1":"F","dropdown-group-2":"D"}

Explanation

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