When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin with erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?
Stage IV
Stage III
Stage I
Stage II
The Correct Answer is D
The correct answer is d) Stage II.
Choice a reason:
Stage IV pressure ulcers are the most severe, with full-thickness skin loss and exposed bone, tendon, or muscle. Signs of stage IV include large-scale tissue loss, possibly including slough or eschar, and may include undermining and tunneling. The scenario described does not indicate such an advanced stage, as there is no mention of exposed deeper tissues or structures.
Choice b reason:
Stage III pressure ulcers involve full-thickness skin loss, potentially affecting subcutaneous tissue but not extending to underlying muscle or bone. The wound may have a crater-like appearance. The described condition does not match stage III, as there is no indication of the ulcer extending into subcutaneous tissue.
Choice c reason:
Stage I pressure ulcers present with intact skin and non-blanchable redness of a localized area usually over a bony prominence. The skin may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. In the given scenario, the skin is not intact, ruling out stage I.
Choice d reason:
Stage II pressure ulcers are characterized by partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. They may also present as intact or ruptured blisters. The description of the skin condition with erythema, serosanguineous drainage, and a blister-like appearance aligns with a stage II pressure ulcer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a reason:
Exophthalmos, or protrusion of the eyeballs, is not a typical finding in hypothyroidism. It is more commonly associated with hyperthyroidism, particularly Graves' disease, which is characterized by an overactive thyroid gland.
Choice b reason:
Photophobia, or light sensitivity, is not a common symptom of hypothyroidism. While it can be associated with other conditions, it is not directly related to the function of the thyroid gland.
Choice c reason:
Weight loss is typically not associated with hypothyroidism. In fact, individuals with hypothyroidism often experience weight gain due to a slowed metabolism, which is the opposite of weight loss.
Choice d reason:
Lethargy is a common symptom of hypothyroidism. The condition can lead to a decrease in thyroid hormone production, which can slow down the body's metabolism, resulting in feelings of fatigue, sluggishness, and lethargy.
Correct Answer is A
Explanation
Choice A Reason:
Vertigo is a common complication associated with inner ear infections, such as labyrinthitis or vestibular neuritis. The inner ear is responsible for balance, and when it is infected, it can lead to a sensation of spinning or dizziness. Interventions may include medications like meclizine or dimenhydrinate to alleviate symptoms, as well as safety measures to prevent falls.
Choice B Reason:
Rhinorrhea, or a runny nose, is not typically a direct complication of an inner ear infection. It may be associated with upper respiratory infections that can precede or accompany an ear infection but is not a result of the inner ear infection itself.
Choice C Reason:
Fever may be present if the inner ear infection is part of a systemic infection, such as the flu or bacterial meningitis. However, fever is not a direct result of an isolated inner ear infection. If fever is present, the nurse should monitor the patient's temperature and may administer antipyretics as ordered.
Choice D Reason:
Headache can be a symptom experienced by individuals with inner ear infections due to the general discomfort and pressure changes in the ear. However, it is not as specific or as common as vertigo when it comes to inner ear infections. If headaches are present, pain management strategies can be included in the care plan.
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