Nokea
Which stage of a pressure injury is exhibited by deeply ulcerated tissue, exposing muscle and bone?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: D
Rationale: Stage IV occurs when the tissue is deeply ulcerated, exposing muscle and bones. Stage III pressure sores are those in which the superficial impairment progresses to a shallow crater that extends to the subcutaneous tissue. Stage I pressure sores are characterized by redness of the skin. Stage II pressure sores are red and accompanied by blistering and a shallow break in the skin.
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The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss?
- A. Radiation
- B. Evaporation
- C. Conduction
- D. Convection
Correct Answer: C
Rationale: Conduction is the transfer of heat through direct contact. Radiation is the transfer of surface heat in the environment. Evaporation is the loss of moisture or water. Convection is the transfer of heat by means of currents of liquids or gases in which warm air molecules move away from the body.
A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?
- A. Macule
- B. Vesicle
- C. Pustule
- D. Cyst
Correct Answer: C
Rationale: A pustule has an elevated, raised border, filled with pus. A macule is a flat, round, colored lesion such as a freckle or rash. A vesicle is a lesion that is elevated, round, and filled with serum. A cyst is an encapsulated, round, fluid-filled or solid mass beneath the skin.
Plantar warts may be treated with what method?
- A. Photochemotherapy
- B. Radiation
- C. Electrodesiccation
- D. Cryosurgery
Correct Answer: C
Rationale: Electrodesiccation is the use of electrical energy converted to heat, which destroys the tissue. Photochemotherapy involves a combination of psoralen methoxsalen and type A ultraviolet light. Radiation therapy is used to treat malignant skin lesions. Cryosurgery is the application of extreme cold to destroy tissue.
The nurse is performing a skin assessment on a client who points out a small, round, flat area of skin that is a different color than the surrounding tissue. What term should the nurse use to document this finding?
- A. Macule
- B. Papule
- C. Vesicle
- D. Wheal
Correct Answer: A
Rationale: The nurse should document this finding as a macule, which describes a flat, round, and colored area of skin. A papule is solid and has an elevated, obvious raised border. A vesicle is elevated, round, and filled with serum. A wheal is elevated, has an irregular border, and contains no free fluid.
The nurse is changing a brief for a client that has been incontinent of stool and observes an area over the left trochanter that is reddened and in the center of the area is a shallow skin tear. The nurse takes a picture of the wound for the chart. How will the nurse stage this wound?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: B
Rationale: A stage II pressure sore is red and is accompanied by blistering or a shallow break in the skin, sometimes described as a skin tear. Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.