When assessing a client's skin, the nurse finds clusters of lesions. How would the nurse document the lesions?

Confluent

Discrete

Grouped

Annular

Answer and Explanation

The Correct Answer is C

A.   Confluent lesions merge together, forming a larger area of affected skin, which is not the case here.
B.   Discrete lesions are separate and distinct from each other, which doesn't match the description of clusters.
C.   Grouped lesions are those that appear in clusters, which fits the assessment finding.
D.   Annular lesions have a ring-like appearance, typically seen in conditions like ringworm, and do not fit the description of clustered lesions.

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Correct Answer is C

Explanation

A. Exposed bone refers to a stage 4 pressure ulcer, which involves full-thickness tissue loss with bone, muscle, or tendon exposure.
B. Blood-filled blisters are more indicative of a stage 2 ulcer, which involves partial-thickness skin loss with blister formation.

C. A stage 3 ulcer is characterized by full-thickness skin loss, with damage extending into subcutaneous tissue, where necrosis may occur.
D. Partial-thickness skin loss is a characteristic of a stage 2 pressure ulcer, not stage 3.

A. Intact skin with localized erythema. B. Partial-thickness skin loss with red tissue in wound bed. C. Full thickness skin loss with visible adipose tissue. D. Full thickness skin loss with visible bone

Correct Answer is B

Explanation

A. Intact skin with localized erythema: This describes a stage 1 pressure injury.
B. Partial-thickness skin loss with red tissue in wound bed: This is characteristic of stage 2 pressure injuries, where there is damage to the epidermis and partial dermis.
C. Full thickness skin loss with visible adipose tissue: This describes a stage 3 pressure injury.
D. Full thickness skin loss with visible bone: This describes a stage 4 pressure injury.

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When assessing a client's skin, the nurse finds clusters of lesions. How would the nurse document the lesions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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