Practice Question
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?
Answer Choices:
Correct Answer:
Necrotic subcutaneous tissue
Rationale:
🔵 Stage 3 pressure injuries show full-thickness skin loss with damage into subcutaneous tissue.
🔵 Necrosis of subcutaneous fat is a classic feature.
🔵 No exposed bone/tendon (Stage 4) or partial skin loss (Stage 2) is present.
🔵 Slough or eschar may be visible but do not obscure the wound base.
🔵 May include undermining and tunneling.
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This question is from RN Health Assessment Exam which contains 36 questions.
More Questions from This Exam
When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.
Answer Choices:
A. Asymmetry of the lesions
B. Red and black coloration
C. Flat
D. 8 mm in diameter
E. Round edges
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
Answer Choices:
A. Check the function of cranial nerve V.
B. Observe for the presence of Kernig's sign
C. Inspect for the presence of clubbing.
D. Perform a Romberg's test.
A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?
Answer Choices:
A. “As a nurse, I am required by law to report suspected child abuse.”
B. "I reported the incident to my supervisor who decided to contact the authorities."
C. "The provider will be coming to explain the situation."
D. ”I am unable to discuss this, but I can contact my supervisor to speak with you."
When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.
Answer Choices:
A. Groin
B. Соссух
C. Heels
D. Scapula
E. Under the breasts
A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer? (Select all that apply.)
Answer Choices:
A. Genetic predisposition
B. Dark skin
C. Previous skin injury
D. Under 40 years of age
E. Overexposure to ultraviolet light
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: Health Assessment
- Answer Choices: 4