You are assessing a client and note a pressure injury on the client’s sacrum. The lesion is a deep depression below the level of skin and into the muscle and there appears to be a spot where the bone is visible. What stage of the pressure injury would you document for this wound?
Stage 4.
Stage 3.
Stage 1.
Stage 2.
The Correct Answer is A
Choice A reason: Stage 4 pressure injury involves full-thickness tissue loss with exposed muscle, bone, or tendon, as described with a deep depression and visible bone. This severe stage requires aggressive interventions like debridement or surgery. Accurate staging ensures proper wound care, preventing infection and promoting healing in advanced pressure injuries.
Choice B reason: Stage 3 involves full-thickness loss to subcutaneous tissue, not muscle or bone, unlike the described injury with visible bone (stage 4). Misstaging as 3 underestimates severity, risking inadequate treatments like simple dressings, delaying surgical intervention or infection control critical for deep pressure injuries with bone exposure.
Choice C reason: Stage 1 is intact skin with erythema, not a deep lesion with bone exposure, which is stage 4. Misstaging as 1 grossly underestimates severity, neglecting urgent needs like debridement or antibiotics, risking infection, sepsis, or further tissue loss in severe pressure injuries requiring advanced wound management.
Choice D reason: Stage 2 involves partial-thickness loss with a shallow wound, not deep muscle or bone exposure, as in stage 4. Misstaging as 2 risks inadequate care, like topical treatments instead of surgical intervention, delaying healing and increasing complications like osteomyelitis in severe pressure injuries with visible bone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Swallowing water tests cranial nerves IX and X, not XI (spinal accessory), which controls trapezius and sternocleidomastoid muscles. Shoulder shrugging tests XI. Misidentifying this risks incorrect neurological assessment, potentially missing deficits in motor function, critical for diagnosing conditions affecting cranial nerve XI in clinical evaluations.
Choice B reason: Saying “light, tight, dynamite” tests cranial nerve XII (hypoglossal) for tongue movement, not XI, which involves shoulder and neck muscles. Assuming this assesses XI misguides neurological evaluation, risking oversight of motor weaknesses, essential for accurate diagnosis and management of cranial nerve-related disorders in patients.
Choice C reason: Identifying a smell tests cranial nerve I (olfactory), not XI, which governs shoulder and neck movements. Misidentifying this risks incorrect cranial nerve assessment, potentially missing motor deficits in XI, critical for diagnosing neurological conditions like nerve injuries or tumors affecting shoulder and neck function.
Choice D reason: Shrugging shoulders and turning the head against resistance tests cranial nerve XI (spinal accessory), assessing trapezius and sternocleidomastoid strength. This ensures accurate neurological evaluation, detecting deficits from nerve damage or lesions, guiding diagnosis and treatment, critical for managing motor function in patients with suspected cranial nerve issues.
Correct Answer is D
Explanation
Choice A reason: Fatigue is not part of BE FAST (Balance, Eyes, Face, Arms, Speech, Time) and is nonspecific, not a primary stroke sign. Facial drooping is critical. Assuming fatigue risks missing urgent stroke symptoms, delaying thrombolytic therapy, essential for minimizing brain damage within the critical time window.
Choice B reason: Fever is not in BE FAST and is not a primary stroke indicator, though it may occur later. Facial asymmetry is a key sign. Assuming fever misdirects assessment, risking delayed stroke recognition, critical for initiating rapid interventions like tPA to restore cerebral perfusion and reduce disability.
Choice C reason: Feet (balance) aligns with “B” in BE FAST, not “F,” which represents facial drooping. Misidentifying this risks confusing stroke assessment, potentially delaying recognition of facial asymmetry, a hallmark sign, critical for prompt stroke intervention to minimize neurological damage and improve patient outcomes.
Choice D reason: In BE FAST, “F” stands for face, assessing facial drooping or asymmetry, a common stroke sign due to cranial nerve VII involvement. It’s critical for rapid identification, enabling timely interventions like thrombolytics within 4.5 hours, minimizing brain damage and improving recovery chances in acute ischemic stroke patients.
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