Which manifestations are associated with fluid excess? (Select all that apply)

Choice A reason: Red warm skin is not typical of pulmonary embolism. It may occur in infections or inflammation. Pulmonary embolism causes reduced lung perfusion, leading to hypoxia and systemic symptoms, not localized skin changes, making this choice incorrect.

Choice B reason: Dizziness occurs in pulmonary embolism due to reduced oxygen delivery to the brain from blocked pulmonary arteries, causing hypoxia. Decreased cardiac output from right heart strain also contributes, making this a correct manifestation of pulmonary embolism.

Choice C reason: Bradycardia is not typical; pulmonary embolism usually causes tachycardia as the heart compensates for hypoxia and increased pulmonary vascular resistance. Slow heart rate does not align with the body’s response to acute obstruction, making this incorrect.

Choice D reason: Hypoxia is a hallmark of pulmonary embolism, as blocked pulmonary arteries impair gas exchange, reducing oxygen in the blood. This leads to tissue oxygen deficiency, causing symptoms like shortness of breath, making this a correct manifestation.

Choice E reason: Chest pain in pulmonary embolism results from pleural irritation or ischemia due to blocked pulmonary arteries. The pain is often sharp and worsens with breathing, reflecting lung tissue stress, making this a correct manifestation.

Choice F reason: Tachypnea, or rapid breathing, occurs as the body attempts to compensate for hypoxia in pulmonary embolism. The respiratory system increases rate to improve oxygenation, a common response to impaired gas exchange, making this correct.

Choice A reason: Stage 1 pressure ulcers present with intact skin showing non-blanchable redness, typically over bony prominences, due to localized ischemia from sustained pressure. No skin loss or blistering occurs, as the epidermis remains intact, indicating early tissue stress without ulceration. This does not match the described blister and skin loss, making it incorrect.

Choice B reason: Stage 4 pressure ulcers involve full-thickness tissue loss, exposing underlying structures like muscle, bone, or tendons. Severe necrosis and deep tissue damage occur due to prolonged pressure, disrupting blood supply extensively. The described superficial skin loss with a blister does not involve such deep structures, ruling out Stage 4.

Choice C reason: Stage 3 pressure ulcers feature full-thickness skin loss, extending into subcutaneous tissue but not to muscle or bone. They may show undermining or tunneling due to tissue necrosis. The described blister with top-layer skin loss suggests partial-thickness damage, not deep enough for Stage 3, making this choice incorrect.

Choice D reason: Stage 2 pressure ulcers involve partial-thickness skin loss, affecting the epidermis and possibly dermis, often appearing as a shallow ulcer or fluid-filled blister. The blister and loss of the top skin layer described indicate damage beyond redness but not full-thickness, aligning perfectly with Stage 2 characteristics, making this the correct choice.