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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?

A.

An area of non-blanchable redness on intact skin..

B.

An area of shallow broken skin with blistering

C.

Deep purple discoloration over intact skin

D.

An open wound with visible adipose tissue and eschar.

Answer and Explanation

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.
 


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Related Questions

Correct Answer is C

Explanation

A. This statement is incorrect. Lispro is a rapid-acting insulin, and its duration of action is much shorter than 24 hours. It is typically effective for about 3-5 hours.
B. Administering Lispro 60 minutes before meals would be too early, as it peaks in about 1-2 hours after injection and works best when given closer to meal times.
C. Lispro should be administered 15-30 minutes before meals to match the onset of action, which begins within 15 minutes of injection. This timing allows the insulin to be active when blood glucose rises after eating.
D. Lispro does not require administration 2-6 hours before meals, as this would not align with its rapid onset of action.

Correct Answer is B

Explanation

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.

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