You are assessing a client admitted from a long-term care facility. When noting a stage II pressure injury on the client's coccyx, which of the following would you expect?
An area of non-blanchable redness on intact skin..
An area of shallow broken skin with blistering
Deep purple discoloration over intact skin
An open wound with visible adipose tissue and eschar.
The Correct Answer is B
A. An area of non-blanchable redness on intact skin is characteristic of a stage I pressure injury, not stage II. In stage I, the skin remains intact but shows redness that does not blanch when pressed.
B. An area of shallow broken skin with blistering describes a stage II pressure injury. Stage II involves partial-thickness loss of skin, which may present as a blister or shallow open ulcer, often with a pink or red wound bed.
C. Deep purple discoloration over intact skin refers to a suspected deep tissue injury, which is a different classification of pressure injury. It indicates damage to underlying tissue but does not involve a break in the skin.
D. An open wound with visible adipose tissue and eschar is indicative of a stage III pressure injury, which involves full-thickness skin loss and may expose underlying structures like fat, but not bone or muscle (which would indicate stage IV). Stage III wounds may also have eschar or slough, but stage II wounds do not.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Prepare the client for a CT scan is not the first priority in this case. A CT scan might be considered if there is suspicion of complications like a kidney stone or abscess, but it is not the first intervention.
B. Begin broad spectrum antibiotics could be considered if a urinary tract infection (UTI) is suspected, but obtaining urine samples for culture and urinalysis is necessary first to confirm the diagnosis and guide antibiotic therapy.
C. Insert a Foley catheter is not indicated unless the patient is unable to void or there is a need for continuous monitoring of urine output, but it is not the first step.
D. Obtain samples for urine culture and urinalysis is the first step to confirm the diagnosis of a urinary tract infection (UTI) and determine the appropriate treatment. This will help guide the selection of antibiotics.
Correct Answer is B
Explanation
A. Assessing blood pressure with a sphygmomanometer is unrelated to Chvostek's sign, which specifically evaluates neuromuscular excitability.
B. Chvostek's sign is assessed by tapping the facial nerve near the cheekbone. A positive response, such as twitching of the facial muscles, indicates hypocalcemia or neuromuscular irritability.
C. Assessing heart rate with a stethoscope does not involve evaluating neuromuscular function or calcium levels.
D. Monitoring respiratory rate with a pulse oximeter is unrelated to Chvostek's sign and does not assess neuromuscular excitability.
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