Practice Question
When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin with erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?
Answer Choices:
Correct Answer:
Stage II
Rationale:
🎯A Stage II pressure ulcer is characterized by partial-thickness skin loss involving the epidermis and/or dermis.
🎯The presence of blister-like appearance, erythema, and serosanguineous drainage confirms skin is broken, but without exposure of subcutaneous tissue, muscle, or bone.
🎯This stage reflects an open, shallow ulcer with a red-pink wound bed and no slough.
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This question is from RN Fundamentals Assessment Midterm Exam which contains 53 questions.
More Questions from This Exam
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Answer Choices:
A. Evaluate the client's responses to treatment.
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C. Monitor risks for alterations in health.
D. Establish a baseline.
A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the physical exam, the nurse notices areas of linear hyperpigmentation around the neck and in the axillae(Acanthosis Nigricans). What would the nurse do next?
Answer Choices:
A. Refer the client for medical follow-up.
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Answer Choices:
A. Diabetes mellitus
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D. Colon cancer
The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?
Answer Choices:
A. In front of the ear.
B. In the midline, a few centimeters behind the tip of the mandible.
C. Superficial to the sternomastoid.
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What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?
Answer Choices:
A. Peripheral vision.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 4
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