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 C

Explanation

A. The overweight category is defined as a BMI between 25 and 29.9.

B. The obese category is defined as a BMI of 30 or above.

C. A BMI below 18.5 is considered underweight, which applies to this client with a BMI of 18.0.

D. A healthy weight category is defined as a BMI between 18.5 and 24.9.

A. Discharge from the eyes B. Presbyopia C. Cataracts D. Xanthelasma E. Macular degeneration

Correct Answer is ["B","C","D","E"]

Explanation

A. Discharge from the eyes is generally a symptom of infection or irritation and not a specific age-related condition.

B. Presbyopia is the age-related loss of near vision, common in older adults.

C. Cataracts, which involve clouding of the lens, are commonly seen with aging.

D. Xanthelasma is a condition in which yellowish deposits of fat form under the skin, usually around the eyes, and it is often seen in older adults.

E. Macular degeneration, which affects central vision, is a common condition in older adults.

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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

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Correct Answer is C

Explanation

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Correct Answer is ["B","C","D","E"]

Explanation

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