The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer.

Stage I

Stage III

Stage IV

Stage II

Answer and Explanation

The Correct Answer is D

Stage I: Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin. There is no break in the skin, but it may appear red and warm to the touch. It is considered the mildest form of pressure injury, signaling the beginning of potential skin damage.

B) Stage III: Stage III pressure ulcers involve full-thickness skin loss. This means that the damage extends through the dermis into the subcutaneous tissue. There may be visible fat, but bone, tendon, and muscle are not exposed. These ulcers are deeper and more serious than the scenario described.

C) Stage IV: Stage IV pressure ulcers are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. The presence of slough or eschar may be present on some parts of the wound bed, and these ulcers are deep, often with extensive damage and infection.

D) Stage II: Stage II pressure ulcers are characterized by partial-thickness skin loss involving the epidermis and/or dermis. They present as shallow, open ulcers with a red-pink wound bed, without slough. They may also appear as intact or open/ruptured serum-filled blisters, which matches the description given in the scenario. This stage represents a more significant injury than Stage I but does not extend into the deeper layers of skin and tissue as in Stage III and IV.

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Correct Answer is A

Explanation

A) Accessibility:

Accessibility refers to the client's ability to obtain food, which is crucial for nutritional status, especially for someone who lives alone and cannot drive. Difficulty in accessing grocery stores or markets can limit the variety and availability of nutritious food options, potentially leading to poor nutritional intake.

B) Food preparation:

Food preparation skills are important, but if the client has difficulty accessing food in the first place (due to transportation limitations), their ability to prepare meals becomes secondary. Accessibility to food sources is a more immediate concern for nutritional status.

C) Food preferences:

While food preferences can influence dietary choices, the ability to access food is a more fundamental issue that directly impacts nutritional intake, especially for someone who lives alone and has limited mobility.

D) Finances:

Financial constraints can certainly affect food choices and access to nutritious options. However, in this scenario, the primary concern is the physical accessibility to food sources, which directly impacts the client's ability to maintain adequate nutrition.

A. Soles of the feet B. Oral mucosa C. Ear lobes D. Conjunctivae

Correct Answer is B

Explanation

(a) Soles of the feet:

The soles of the feet are not considered the most reliable indicator of central cyanosis because peripheral areas can be affected by various factors, including temperature and circulation. Changes in color here might not accurately reflect central oxygenation status.

(b) Oral mucosa:

The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygenation status of the central circulatory system. Cyanosis in this area indicates a significant drop in arterial oxygen saturation and is a more direct indicator of hypoxemia compared to peripheral sites.

Ear lobes, like the soles of the feet, can be influenced by peripheral circulation and environmental factors. While cyanosis can be observed here, it is not as reliable as central sites like the oral mucosa for assessing systemic oxygenation.

(d) Conjunctivae:

The conjunctivae can show signs of cyanosis, but the oral mucosa is still a more sensitive and reliable indicator for central cyanosis. The oral mucosa provides a clear and consistent site to assess oxygenation in emergency situations.

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The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

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