What statement describes a stage 2 pressure ulcer/injury?
Reddened skin that does not blanch when pressed.
The skin is damaged through the muscles and bones.
Damage to the skin extends into the adipose layer.
The top layer of skin is lost and a blister is formed.
The Correct Answer is D
Rationale:
A. Stage 1 pressure ulcer: This stage presents as non-blanchable erythema (redness) of intact skin, usually over a bony prominence. The skin is still intact, and there is no open wound. While the area may be painful, firm, soft, warmer, or cooler than surrounding tissue, the epidermis is not broken. This is why option A is incorrect for a stage 2 ulcer.
B. Stage 4 pressure ulcer: At this stage, full-thickness skin loss occurs, extending into muscle, bone, or supporting structures. This severe damage often exposes tendons or bone and carries a high risk of infection. Option B is incorrect because stage 2 ulcers do not involve muscle or bone.
C. Stage 3 pressure ulcer: This stage involves full-thickness skin loss extending into the subcutaneous tissue, possibly down to the underlying fascia. The adipose layer may be visible, but muscle, tendon, and bone are not exposed. Stage 3 is deeper than stage 2, making option C incorrect.
D. Stage 2 pressure ulcer: This stage is characterized by partial-thickness skin loss involving the epidermis and possibly the dermis. It may appear as an open blister, abrasion, or shallow crater. The wound is typically red-pink without slough and does not expose deeper tissues such as fat, muscle, or bone. Stage 2 ulcers indicate early tissue damage but require careful monitoring to prevent progression to deeper stages.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Tumors do not typically cause pain by lowering body temperature. Changes in core temperature are generally systemic effects, not direct causes of pain.
B. Parasympathetic activation generally reduces heart rate and promotes rest-and-digest activities. Pain associated with tumors is not caused by parasympathetic nervous system activity.
C. Tumors can cause pain primarily through local tissue inflammation, which irritates nearby nerves. Tumor growth can also lead to compression of nerves, blood vessels, or organs, increasing pain intensity. Additionally, inflammatory mediators such as prostaglandins, bradykinin, and cytokines sensitize nerve endings, contributing to nociceptive pain. This mechanism is common in both benign and malignant tumors, though malignant tumors often cause more intense pain due to rapid growth and tissue invasion.
D. While serotonin plays a role in mood regulation and some pain pathways, tumor-related pain is not primarily caused by increased serotonin release. The main contributors are inflammation, nerve compression, and tissue invasion.
Correct Answer is A
Explanation
Rationale:
A. Cellulitis is a bacterial infection of the skin and subcutaneous tissue that can occur when a pressure ulcer breaks the skin barrier. Open wounds provide a pathway for bacteria, most commonly Staphylococcus aureus or Streptococcus species, to enter underlying tissues, leading to redness, swelling, warmth, pain, and potentially systemic infection. This makes cellulitis a common and serious complication of pressure ulcers if not treated promptly.
B. While chronic blood loss or poor nutrition can contribute to anemia, it is not a direct complication of a pressure ulcer. Anemia may be present in patients with multiple comorbidities but is not caused specifically by pressure injuries.
C. Osteoarthritis is a degenerative joint disease unrelated to pressure ulcers. While immobility from severe pressure injuries could worsen joint function, osteoarthritis is not a direct complication.
D. Diabetes is a risk factor for developing pressure ulcers due to poor circulation and impaired wound healing, but it is not caused by pressure ulcers.
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