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 C

Explanation

A) Loss of vision in one eye:

Loss of vision in one eye is not related to hyperopia (farsightedness). This condition could be due to various other causes such as retinal detachment, optic neuropathy, or trauma, but it does not describe the refractive error associated with hyperopia.

B) Clear vision of nearby objects, but difficulty seeing distant objects:

This description pertains to myopia (nearsightedness), where individuals can see nearby objects clearly but struggle with seeing distant objects. Hyperopia is the opposite, involving difficulty with near vision rather than distance vision.

C) Clear vision of distant objects, but difficulty seeing nearby objects:

Hyperopia, or farsightedness, is characterized by clear vision of distant objects while nearby objects appear blurry. This occurs because the eye's light focuses behind the retina rather than directly on it, making close-up tasks like reading challenging.

D) Blurry vision of both distant and nearby objects:

Blurry vision of both distant and nearby objects is not specific to hyperopia and may indicate other eye conditions such as astigmatism or severe refractive errors that affect overall visual acuity, rather than the specific issue of near vision seen in hyperopia.

A. Dysphagia B. gingivitis C. aphthous ulcers. D. Hypothyroidism

Correct Answer is D

Explanation

A) Dysphagia:

Dysphagia refers to difficulty swallowing and is typically associated with conditions affecting the esophagus or neuromuscular function. While it can coexist with other symptoms, it does not directly explain hoarseness, fatigue, and weight gain as hypothyroidism does.

B) Gingivitis:

Gingivitis is an inflammation of the gums due to plaque buildup. It primarily affects oral health, causing redness, swelling, and bleeding of the gums. It is not associated with systemic symptoms like hoarseness, fatigue, or weight gain.

C) Aphthous ulcers:

Aphthous ulcers, also known as canker sores, are small, painful lesions that develop in the mouth. They are typically caused by stress, minor injury, or certain foods. These ulcers do not explain the systemic symptoms described by the client.

D) Hypothyroidism:

Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. Symptoms include hoarseness, fatigue, weight gain, dry skin, and cold intolerance. The combination of these symptoms in the client's history makes hypothyroidism the most likely cause.

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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

Which of the following best describes Hyperopia?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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