The nurse is assessing the chest shape of a patient.
Which chest configuration describes a sunken in sternum and costal cartilage?

Choice A rationale

Myopia, or nearsightedness, is when distant objects appear blurry because light rays focus in front of the retina. A Snellen exam result of 20/50 means the client can see at 20 feet what someone with normal vision sees at 50 feet, indicating reduced distance vision. However, this condition does not correlate with the ability to read the Rosenbaum chart, which is for near vision, thus excluding myopia.

Choice B rationale

Normal vision is not indicated by a Snellen exam result of 20/50, as this signifies a visual impairment where the client sees at 20 feet what a person with normal vision sees at 50 feet. Normal vision would be indicated by 20/20 on the Snellen exam.

Choice C rationale

Presbyopia is the age-related loss of the eye's ability to focus on near objects, typically noticeable in people over 40. Although this condition involves difficulty reading at close range, the client's uncorrected Snellen exam result of 20/50 pertains to distance vision, which differentiates presbyopia from the given scenario.

Choice D rationale

Hyperopia, or farsightedness, is when close objects appear blurry because light rays focus behind the retina. The client's ability to read the Rosenbaum chart without difficulty indicates good near vision, while the Snellen exam result of 20/50 reflects reduced distance vision, thus supporting the diagnosis of hyperopia.

Choice A rationale

Patches of eschar covering parts of the wound are characteristic of more advanced pressure ulcers, such as Stage III or IV, where necrotic tissue is present. Eschar is a dark, thick, leathery scab or crust that indicates deeper tissue damage and is not observed in Stage II pressure ulcers.

Choice B rationale

A Stage II pressure ulcer is characterized by partial thickness skin erosion with loss of the epidermis and dermis. It appears as a shallow open ulcer with a red-pink wound bed, indicating that the damage has not extended beyond these layers of skin.

Choice C rationale

When a pressure ulcer extends into the subcutaneous tissue, it is classified as a Stage III or IV ulcer, depending on the depth and extent of tissue involvement. Stage II ulcers are limited to the epidermis and dermis and do not reach the subcutaneous layer.

Choice D rationale

Intact skin that appears red but is not broken is indicative of a Stage I pressure ulcer, which represents the earliest stage of pressure injury. Stage I ulcers involve non-blanchable erythema (redness) but no open wound or skin erosion.

Choice E rationale

Open blister areas with a red-pink wound bed are characteristic of Stage II pressure ulcers. These ulcers exhibit partial thickness skin loss and can present as open or fluid-filled blisters with a visible wound bed.

Choice F rationale

Localized redness in light skin that blanches with fingertip pressure is typical of a Stage I pressure ulcer. Blanching erythema indicates that the skin is still viable and blood flow is present, which differentiates Stage I from more advanced stages of pressure injury.