What statement would best define stage 2 pressure injury?
Full-thickness skin and tissue loss where subcutaneous fat is visible
Full-thickness skin and tissue loss where muscle, fascia, or bone is visible
Partial thickness skin loss with exposed dermis
Nonblanchable erythema of intact skin
The Correct Answer is C
A. Full-thickness skin and tissue loss where subcutaneous fat is visible: This description corresponds to a stage 3 pressure injury. Stage 3 injuries extend through the dermis into the subcutaneous tissue, exposing fat and sometimes leading to tunneling or undermining, which is deeper than a stage 2 injury.
B. Full-thickness skin and tissue loss where muscle, fascia, or bone is visible: This describes a stage 4 pressure injury. Stage 4 injuries involve extensive tissue destruction, exposing muscle, tendon, or bone, and often carry high risk for infection and complications.
C. Partial thickness skin loss with exposed dermis: Stage 2 pressure injuries involve partial-thickness loss of the epidermis and possibly the dermis, presenting as a shallow open ulcer or blister. The wound bed is typically red or pink and moist, without slough, and does not extend into subcutaneous tissue, distinguishing it from deeper stages.
D. Nonblanchable erythema of intact skin: This describes a stage 1 pressure injury, characterized by intact skin with localized redness that does not blanch with pressure. Stage 1 injuries indicate early skin compromise without actual tissue loss, unlike stage 2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E","F","G"]
Explanation
A. Ability to sense pain: Assessing the client’s sensory perception of pain is an important component of skin assessment. It helps identify areas of neuropathy, pressure injury risk, or impaired protective sensation that could lead to unrecognized skin trauma.
B. Amplitude: Amplitude is not a standard component of a skin assessment; it is usually used to describe pulse strength in cardiovascular assessment. Including it does not provide information about skin integrity or condition.
C. Turgor: Skin turgor indicates hydration status and elasticity. Poor turgor, such as tenting, can signal dehydration or aging-related changes, making it a critical parameter in evaluating skin health.
D. Temperature: Assessing skin temperature helps identify areas of infection, inflammation, or poor perfusion. Localized warmth may indicate infection, whereas cool or cold areas may suggest impaired blood flow.
E. Color: Skin color assessment identifies changes in perfusion, oxygenation, or pathology. Cyanosis, pallor, erythema, or jaundice are all detected through careful evaluation of skin color.
F. Moisture: Moisture levels indicate the presence of sweating, dehydration, or incontinence-related skin issues. Overly dry or excessively moist skin increases the risk for breakdown and infection.
G. Edema: Checking for edema evaluates fluid accumulation in tissues, which can impair circulation and increase susceptibility to skin breakdown, particularly in dependent areas.
Correct Answer is C
Explanation
A. Consult physical therapy: While involving physical therapy is important for safe mobilization and rehabilitation, the patient’s current pain level must be managed first to allow participation in therapy. Uncontrolled pain can limit mobility, increase the risk of falls, and impair recovery outcomes.
B. Assist the patient to walk in the room with crutches: Attempting ambulation without addressing the patient’s pain may worsen discomfort, increase anxiety, and risk injury. Pain control is necessary before safe and effective mobilization can occur.
C. Administer pain medication: The priority intervention is to relieve the patient’s pain to a manageable level. Effective pain management enables safe ambulation, improves cooperation with physical therapy, and reduces stress responses that can impede healing after a fracture.
D. Assist the patient to walk in the room with crutches: This is a duplicate of option B, reinforcing that walking should be attempted only after the patient’s pain has been addressed. Prioritizing pain relief ensures mobility interventions are safe and tolerable.
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