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) The patient is unable to see in half of the visual field (same visual field) in each eye:

Homonymous hemianopsia is a condition where there is a loss of vision in the same side of the visual field in both eyes. This occurs due to damage to the visual pathways after the optic chiasm, often from a stroke or brain injury, resulting in the loss of either the right or left visual field in both eyes.

b) The patient can see from one eye but not through the other one:

This description fits a condition called monocular blindness, which is typically caused by damage to the optic nerve before it reaches the optic chiasm. Homonymous hemianopsia involves both eyes and specific visual fields, not complete loss of vision in one eye.

c) The patient is unable to see in half of the visual field (opposite visual field) in each eye:

This option describes bitemporal hemianopsia, which results in loss of vision in the outer (temporal) fields of both eyes and is often due to damage at the optic chiasm. Homonymous hemianopsia involves the same side of the visual field in both eyes, not the opposite visual fields.

d) No visual impairment:

Homonymous hemianopsia is characterized by significant visual impairment, specifically the loss of half the visual field in both eyes on the same side. Therefore, it is incorrect to say there is no visual impairment with this condition.

A. Accessibility B. Food preparation C. Food preferences D. Finances

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.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is diagnosed with Homonymous Hemianopsia. The nurse expects to find what defects in the visual field of this patient:

Correct Answer is A

Explanation

A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status?

Correct Answer is A

Explanation

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