What characteristic(s) describe a stage 1 pressure ulcer/injury? Select all that apply.
Fastest healing pressure ulcer
Damage extends to the adipose layer
Top layer of skin is lost and looks like a blister
Temperature differs from the surrounding skin
Skin is red and non-blanchable
Correct Answer : A,D,E
Rationale:
A. Stage 1 pressure ulcers are superficial and do not involve tissue loss, making them the fastest to heal among all pressure ulcer stages. Healing can occur within days to weeks if pressure is relieved, and proper skincare and nutrition are provided. Early detection is crucial to prevent progression to deeper stages, which are more difficult to treat and may involve surgical intervention.
B. Damage extending into the adipose layer indicates a stage 3 pressure ulcer, which involves full-thickness skin loss and deeper tissue involvement. Stage 1 ulcers are limited to the epidermis without penetration into underlying fat or muscle.
C. Loss of the epidermis or formation of a blister is characteristic of stage 2 pressure ulcers, where the injury is partial-thickness. Stage 1 ulcers do not break the skin; the skin remains intact but shows redness or other changes.
D. Stage 1 pressure ulcers may present with localized changes in temperature. The area may feel warmer than surrounding tissue due to inflammation or cooler if perfusion is compromised. Temperature changes can be an early indicator of tissue stress before visible breakdown occurs, making assessment of skin temperature important in prevention.
E. The hallmark of a stage 1 pressure ulcer is persistent redness that does not blanch when pressed. Non-blanchable erythema indicates damage to underlying capillaries, even though the epidermis remains intact. The area may also be painful, firm, or softer compared to surrounding tissue, signaling early tissue compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Cleaning toys helps reduce environmental contamination, but it is not as immediate or consistent in preventing the spread of infections compared with hand hygiene. Contaminated hands can transfer pathogens to other children or surfaces before toys are cleaned, so this alone is insufficient.
B. Hand hygiene is the single most effective measure to interrupt the transmission link in the chain of infection. Preschool children frequently touch their faces, toys, and each other, making hands the primary vehicle for pathogens. Proper handwashing with soap and water or using hand sanitizer removes infectious agents, preventing spread to other children and surfaces. This measure addresses direct and indirect transmission, which is critical in group settings like preschools.
C. Good nutrition strengthens the immune system, but it does not immediately prevent transmission of pathogens. While it supports overall health and infection resistance, it does not break the chain of infection in the short term.
D. Multivitamins may support immunity but do not directly prevent transmission. They have no immediate effect on stopping pathogens from moving from one child to another.
Correct Answer is C
Explanation
Rationale:
A. B-memory cells are derived from B lymphocytes, not basophils. Basophils do not participate directly in antibody production or memory formation.
B. Basophils are not phagocytic cells. Phagocytosis is primarily performed by neutrophils, macrophages, and dendritic cells. Basophils function mainly in mediating inflammatory responses, especially allergic reactions.
C. Basophils are granulocytes that circulate in the blood and play a key role in type I hypersensitivity reactions (allergic reactions). They bind to IgE antibodies on their surface. Upon exposure to an allergen, cross-linking of IgE triggers degranulation, releasing histamine, leukotrienes, and other inflammatory mediators. This causes vasodilation, increased vascular permeability, smooth muscle contraction, and the classic symptoms of anaphylaxis, such as swelling, hives, and airway constriction.
D. Monocytes, not basophils, leave the bloodstream to differentiate into macrophages in tissues. Basophils remain as circulating granulocytes and do not transform into other cell types.
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