HESI Questions Part 2 - Health and Physical Assessment

The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate? 1. Yin/Yang balance 2. Biomedical belief 3. Determinism belief 4. Magicoreligious belief

4. Magicoreligious belief

Which factor can elevate the oxygen saturation during an assessment? 1. Nail polishes 2. Carbon monoxide 3. Intravascular dyes 4. Skin pigmentation

2. Carbon monoxide Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestimate the saturation.

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding? 1. Skin condition 2. Fluid and electrolyte balance 3. Food intake 4. Fluid intake and output

2. Fluid and electrolyte balance

When should the nurse consider family members as the primary source of information? (Choose all that apply) 1. The client is an elderly adult. 2. The client is an infant or child. 3. The client is brought in as an emergency. 4. The client is critically ill and disoriented. 5. The client visits the outpatient department.

2. The client is an infant or child. 3. The client is brought in as an emergency. 4. The client is critically ill and disoriented.

A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident indicates the need for further teaching? 1. "Type I immune response to latex has an immediate onset." 2. "Type I immune reaction to latex leads to release of IgE antibodies." 3. "The client's first exposure to latex will cause a type IV allergic reaction." 4. "Type IV immune response to latex occurs after 12 to 48 hours after exposure."

3. "The client's first exposure to latex will cause a type IV allergic reaction."

A pregnant woman in her second trimester arrived at the hospital for a general health checkup. The physician recommended a pelvic examination to the client. Which position is most suitable for assessing the client in this condition? 1. Sims position 2. Supine position 3. Lithotomy position 4. Dorsal recumbent position

3. Lithotomy position Lithotomy position provides maximum exposure to the female genitalia and easy examination of the region. Therefore this position is recommended for examining pregnant women. Sims position is indicated for rectal and vaginal examinations. Supine position is recommended for examining anterior thorax, lungs, breasts, axilla, heart abdomen, extremities, and pulse. Dorsal recumbent position is mainly indicated to examine the abdomen because it promotes abdominal relaxation.

A nurse is assessing several clients. Which client will require parenteral nutrition? 1. A client with brain neoplasm 2. A client with anorexia nervosa 3. A client with inflammatory bowel disease 4. A client with severe malabsorption disorder

4. A client with severe malabsorption disorder

While performing a physical assessment of a client, a nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. What is the probable etiology for this condition? 1. Anemia 2. Pregnancy 3. Lung disease 4. Autoimmune disease

4. Autoimmune disease Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced amount of oxyhemoglobin. A tan-brown color of the skin is noticed in pregnancy due to an increased amount of melanin. Lung disease or heart failure can cause cyanosis due to an increased amount of deoxygenated hemoglobin.

A client has a history of a persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk should be assessed? 1. Lung cancer 2. Cerebrovascular disease 3. Cardiopulmonary alterations 4. Human immunodeficiency virus (HIV) infection

4. Human immunodeficiency virus (HIV) infection

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? 1. Respirations of 10 2. Urine output of 30 mL/hour 3. Lethargy 4. Restlessness

4. Restlessness

A client with recent history of head trauma is at risk of orthostatic hypotension. Which assessment findings would help to diagnose the condition? (Choose all that apply) 1. Fainting 2. Headache 3. Weakness 4. Light headedness 5. Shortness of breath

1. Fainting 3. Weakness 4. Light headedness

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience? 1. Visceral pain 2. Somatic pain 3. Referred pain 4. Intractable pain

1. Visceral pain Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. Referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other than its actual source. Intractable pain is a neuropathic pain that is severe, constant pain that is not curable.

The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? (Choose all that apply) 1. "I had a late onset of menarche." 2. "My first child was born when I was 32." 3. "I noticed a slight discharge from a nipple." 4. "I perform breast self-examinations frequently." 5. "I consume two to four glasses of alcohol a day."

2. "My first child was born when I was 32." 3. "I noticed a slight discharge from a nipple." 5. "I consume two to four glasses of alcohol a day."

What would be the respiratory rate in two-year-old child? 1. 20 2. 30 3. 40 4. 50

2. 30 The normal range for the respiratory rate in a two-year-old kid (toddler) is between 25 and 32 breaths per minute. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40. The normal respiratory rate in infants is 50 breaths per minute.

Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? 1. Loosening of the sutures 2. Sharp increase in serosanguineous drainage 3. Purplish color of the incision 4. Protrusion of organs through an open incision

2. Sharp increase in serosanguineous drainage Serosanguineous drainage from the wound or on the dressing forewarns separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration). Loosening of sutures may occur after the initial wound edema subsides, but is not a sign of failure of the suture line. A purplish incision is the expected coloration of a healing wound.

When teaching about aging, the nurse explains that older adults usually have what characteristic? 1. Inflexible attitudes 2. Periods of confusion 3. Slower reaction times 4. Some senile dementia

3. Slower reaction times A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. Most older adults do not have organic mental disease.

While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings? 1. Syphilis 2. Iron deficiency anemia 3. Subacute bacterial endocarditis 4. Chronic obstructive pulmonary disease

3. Subacute bacterial endocarditis Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute bacterial endocarditis, or trichinosis and are called splinter hemorrhages. Conditions such as syphilis and iron deficiency anemia cause concavely curved nails, called koilonychia. Heart and lung abnormalities such as chronic obstructive pulmonary disease cause clubbing of the nail beds.

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond? 1. "You need to receive the pneumococcal vaccine every other year." 2. "The pneumococcal vaccine should be received in early autumn every year." 3. "You should get the flu and pneumococcal vaccines at your annual physical examination." 4. "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."

4. "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."

Which of the following is a description of the percussion technique? 1. Listening to sounds that the body makes 2. Using the sense of touch to assess and collect data 3. Carefully looking for abnormal findings 4. Tapping the skin with the fingertips to vibrate underlying tissues

4. Tapping the skin with the fingertips to vibrate underlying tissues

While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation? 1. 1+ 2. 2+ 3. 3+ 4. 4+

1. 1+ A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.

The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume? 1. 70 mL 2. 60 mL 3. 50 mL 4. 40 mL

1. 70 mL Cardiac output is obtained by multiplying the heart rate and the stroke volume. Therefore to obtain the stroke volume, the cardiac output should be divided by pulse rate. Dividing 5950 by 85 yields a stroke volume of 70 mL.

Which clients should be considered for assessing the carotid pulse? (Choose all that apply) 1. Client with cardiac arrest 2. Client indicated for Allen test 3. Client under physiologic shock 4. Client with impaired circulation to foot 5. Client with impaired circulation to hand

1. Client with cardiac arrest 3. Client under physiologic shock Carotid pulse is indicated in clients with physiologic shock or cardiac arrest when other sites are not palpable in the client. Assessment of the ulnar pulse is indicated in clients requiring an Allen test. Assessment of posterior tibial pulse and dorsalis pedis pulse is indicated in clients with impaired circulation to the feet. Assessment of the radial and ulnar pulse is indicated in clients with impaired circulation to the hands.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? (Choose all that apply) 1. Oral temperature of 98.2° F (36.8° C) 2. Apical pulse of 88 beats per minute and regular 3. Respiratory rate of 30 per minute 4. Blood pressure of 116/78 mm Hg while in a sitting position 5. Oxygen saturation of 92%

1. Oral temperature of 98.2° F (36.8° C) 2. Apical pulse of 88 beats per minute and regular 4. Blood pressure of 116/78 mm Hg while in a sitting position

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? 1. Oxygen Saturation: 89% 2. Body temperature: 101°F 3. Blood Pressure: 130/80 mmHg 4. Respiratory rate: 26 beats/minute

1. Oxygen Saturation: 89% An oxygen saturation less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? 1. Pain history, including location, intensity, and quality of pain 2. Client's purposeful body movement in arranging the papers on the bedside table 3. Pain pattern, including precipitating and alleviating factors 4. Vital signs, such as increased blood pressure and heart rate 5. The client's family statement about increases in pain with ambulation

1. Pain history, including location, intensity, and quality of pain 3. Pain pattern, including precipitating and alleviating factors

While demonstrating the method of measuring blood pressure to a student nurse, the registered nurse measures the blood pressure in a client as 130/80 mm Hg. After the demonstration, when the student nurse is measuring the blood pressure in the same client, it is found to be 120/90 mm Hg. What could be the possible reasons for this difference? (Choose all that apply) 1. Poor fitting of the cuff 2. Inflating the cuff too slowly 3. Deflating the cuff too quickly 4. Inflating the cuff inadequately 5. Applying the stethoscope too firmly

1. Poor fitting of the cuff 3. Deflating the cuff too quickly

While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess the pulse deficit? 1. Radial and apical pulse 2. Apical and carotid pulse 3. Radial and brachial pulse 4. Apical and temporal pulse

1. Radial and apical pulse Pulse deficit may be associated with an abnormal rhythm. Pulse deficit is the difference between the radial and apical pulse. The carotid pulse is measured when a client's condition worsens suddenly. The brachial pulse is used to measure blood pressure. The temporal pulse is used to assess the pulse in children.

The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster? (Choose all that apply) 1. The client reports pain with movement. 2. The client has pain over the surgical area. 3. The client wants to know when he can go home. 4. The client rates the pain as 8 on a scale of 0 to 10. 5. The client has concerns about caring for the wound.

1. The client reports pain with movement. 2. The client has pain over the surgical area. 4. The client rates the pain as 8 on a scale of 0 to 10.

A nurse teaches an obese client measures to calculate the body mass index. Which of these statements by the client indicate effective learning? (Choose all that apply) 1. "I should include sugared beverages in my diet." 2. "I should lose at least half a pound to a pound each week." 3. "My daily nutritional fat intake should be more than 30%." 4. "I'll make sure to eat foods that meet my daily nutritional requirement." 5. "I should stay away from unhealthy foods between meals and after dinner."

2. "I should lose at least half a pound to a pound each week." 4. "I'll make sure to eat foods that meet my daily nutritional requirement." 5. "I should stay away from unhealthy foods between meals and after dinner."

The registered nurse is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning? 1. "The client claims to feel fat despite being underweight." 2. "The client experiences recurrent episodes of binge eating." 3. "The client exhibits intense fear of gaining weight although underweight." 4. "The client refuses to maintain body weight over a minimal ideal body weight."

2. "The client experiences recurrent episodes of binge eating." Bulimia nervosa is an eating disorder in which the client has an obsessive desire to lose weight. In this condition, bouts of extreme overeating are followed by fasting or self-induced vomiting. A recurrent episode of binge eating is an indicator of bulimia nervosa. A client claims to feel fat despite being underweight may have anorexia nervosa. Other assessment findings of anorexia nervosa include an intense fear of gaining weight despite being underweight and a refusal to maintain a body weight over a minimal ideal body weight.

A client arrives at a health clinic stating, "I am here to have my tuberculin skin test read." The nurse notes that there is a 7-mm indurated area at the injection site. Which statement made by the nurse correctly describes this result? 1. "The result indicates that you have active tuberculosis." 2. "The result indicates that you are infected with the tuberculosis organism." 3. "The result indicates that there are no tuberculin antibodies in your system." 4. "The result indicates that you have a secondary infection related to the tuberculin organism."

2. "The result indicates that you are infected with the tuberculosis organism."

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be? 1. 29° C 2. 33° C 3. 36° C 4. 38° C

2. 33° C A body temperature in the range of 36° to 38 ° C is normal. When skin temperature drops below 35° C, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 30° C represents severe hyperthermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client's temperature is most likely 33° C.

The student nurse prepares a concept map while caring for a client recovering from surgery. What is the first step that the student nurse should take when preparing the concept map? 1. Assess the client and gather information. 2. Arrange cues into clusters that form patterns. 3. Identify patterns reflecting the client's problem. 4. Identify specific nursing diagnoses for the client.

2. Arrange cues into clusters that form patterns. A concept map is a visual representation of the connection between the client's many health problems. The first step is to arrange all the cues into clusters that form patterns. This helps the nurse identify specific nursing diagnoses for the client. During the assessment stage, the nurse assesses the client and gathers information. This step is performed before preparing the concept map. After placing all cues into clusters, the nurse begins to identify patterns reflecting the client's problem. The concept map helps the nurse obtain a holistic view of the client's needs. The next step is to identify specific diagnoses so that appropriate nursing interventions can be provided.

A nurse is performing physical assessment of four female clients who came for a general checkup. Which client is most at risk of developing breast cancer? 1. Client A: Age 60, family hx of breast cancer, 2 children, age of onset of menopause at 45 2. Client B: Age 60, family hx of breast cancer, no children, age of onset of menopause at 50 3. Client C: Age 60, no family hx of breast cancer, no children, age of onset of menopause at 50 4. Client D; Age 60, no family hx of breast cancer, 2 children, age of onset of menopause at 45

2. Client B: Age 60, family hx of breast cancer, no children, age of onset of menopause at 50

A registered nurse (RN) is performing a physical assessment of four clients with various medical conditions as shown in the chart. Which client is expected to have concavely curved nails? 1. Client A: subacute endocarditis 2. Client B: Iron deficiency anemia 3. Cyanotic heart disease 4. Chronic obstructive pumlonary disease

2. Client B: Iron deficiency anemia Conditions such as iron deficiency anemia and syphilis cause concave curvature of the nails, which is called koilonychia (spoon nails). Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, or trichinosis. They are called splinter hemorrhages. Softening of the nail bed and enlargement of the finger tips with flattened nails are signs of clubbing of nails, which is seen in conditions of oxygen deficiency such as in heart or pulmonary diseases, cyanotic heart disease, and chronic obstructive pulmonary disease.

A nurse is assessing four different clients. Which findings depict that the client is at risk for heart disease? 1. Client A: color assessed - red, location assessed - face, area of trauma, sacrum, shoulders 2. Client B: color assessed - blue, location assessed - nail beds, lips, mouth, skin 3. Client C: color assessed - pallor, location assessed - face, conjunctivae, nail beds, palms of hand 4. Client D: color assessed - yellow-orange, location assessed - sclera, mucous membranes, skin

2. Client B: color assessed - blue, location assessed - nail beds, lips, mouth, skin

The symptoms of four clients with different levels of impaired vision are given below: Which client is expected to be diagnosed with macular degeneration? 1. Client A: impaired near vision 2. Client B: loss of central vision 3. Client C: cross appearance of eyes 4. Client D: inability to see distant objects

2. Client B: loss of central vision Client B's loss of central vision is caused by macular degeneration. Impaired near vision in client A is due to presbyopia or hyperopia. Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously; this results in the cross appearance of eyes, as seen in client C. Client D's inability to see distant objects is caused by myopia.

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit? 1. Presence of dry skin 2. Loss of body weight 3. Decrease in blood pressure 4. Altered general appearance

2. Loss of body weight Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb (1 kg). Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (e.g., hypothyroidism). Although hypovolemia eventually will result in a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of hypotension. Altered appearance is too general and not an objective determination of fluid volume deficit.

A registered nurse (RN) is instructed to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients? 1. Axilla 2. Oral cavity 3. Temporal artery 4. Tympanic membrane

2. Oral cavity The oral cavity is the preferred site for temperature measurement in adult clients. This site is contraindicated for neonates and unconscious or uncooperative clients. The axilla is a safe site for placing a thermometer in neonates. The temporal artery is indicated for rapid temperature measurement. This site is indicated for premature infants, newborns, and children. The tympanic membrane is indicated in newborns to reduce infant handling and heat loss.

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion? 1. The client's temperature returns to an acceptable value at least once in the past 24 hours 2. The client's fever spikes and falls without a return to normal temperature levels 3. Periods of febrile episodes and periods with acceptable temperature values occur 4. The client has a constant body temperature continuously above 38°C with minimal fluctuation

2. The client's fever spikes and falls without a return to normal temperature levels In a remittent pattern of fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in a 24 hour interval, the fever has an intermittent pattern. Periods of febrile episodes and periods with acceptable temperature values is a relapsing type of fever. In a sustained fever, the body temperature is constantly above 38°C and has little fluctuation.

While examining a client, a nurse finds a circumscribed elevation of the skin filled with serous fluid on the cheek. The lesion is 0.6 cm in diameter. What does the nurse suspect the finding to be? 1. Papule 2. Vesicle 3. Nodule 4. Pustule

2. Vesicle A circumscribed elevation of the skin that is filled with serous fluid and a lesion size of less than 1 cm describes a vesicle. A papule is palpable, circumscribed, and has a solid elevation and a size smaller than 1 cm. A nodule is an elevated solid mass, deeper and firmer than a papule and of 1-2 cm in diameter. A pustule is a circumscribed elevation of the skin that is similar to a vesicle but filled with pus and varies in size.

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk? 1. Eggs 2. Yogurt 3. Potatoes 4. Applesauce

2. Yogurt Yogurt, which contains calcium, is digested more easily than milk because it contains the enzyme lactase, which breaks down milk sugar

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response? 1. "You will need to ask your healthcare provider; it is not part of the usual tests for people your age." 2. "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." 3. "It is performed routinely starting at your age as part of an assessment for colon cancer." 4. "There must have been a positive finding after a digital rectal examination performed by your healthcare provider."

3. "It is performed routinely starting at your age as part of an assessment for colon cancer." The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

Which assessment is expected when a client is placed in the lithotomy position during physical examination? 1. Assessment of the heart 2. Assessment of the rectum 3. Assessment of the female genitalia 4. Assessment of the musculoskeletal system

3. Assessment of the female genitalia Lithotomy position in female clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indicated in clients to assess the heart. The knee-chest position and Sims position are recommended for clients undergoing rectal examinations. The prone position is indicated in clients to assess the musculoskeletal system.

Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels? 1. Contusion 2. Thrombosis 3. Atherosclerosis 4. Tourniquet effect

3. Atherosclerosis In atherosclerosis, there may be changes in the integrity of the walls of the arteries and smaller blood vessels. Direct manipulation of vessels or localized edema that impairs blood flow will lead to a contusion. Blood clotting that causes mechanical obstruction to blood flow indicates thrombosis. The tourniquet effect may be caused by the application of constricting devices, which may lead to impaired blood flow to areas below the site of constriction.

A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child? 1. Avoid answering questions. 2. Give the child a list of expectations. 3. Be consistent about established rules. 4. Allow the child to plan the day's activities.

3. Be consistent about established rules. Because of a short attention span and distractibility, consistent limit setting is essential toward providing an environment that promotes concentration, prevents confusion, and minimizes conflicts. Questions should be answered, but the answers should not be judgmental. A list of expectations may be overwhelming at this age. Parents need to assist children with routine tasks; children this age may not be concerned with time frames.

While assessing a 7-month-old infant, the nurse advises the mother to avoid regular cow's milk. Which of these are valid reasons for the suggestion? (Choose all that apply) 1. Cow's milk is not tolerated by infants. 2. Cow's milk is a potential source of botulism toxin. 3. Cow's milk increases the risk of milk product allergies. 4. Cow's milk is a poor source of iron and vitamins C and E. 5. Cow's milk is too concentrated for an infant's kidneys to manage.

3. Cow's milk increases the risk of milk product allergies. 4. Cow's milk is a poor source of iron and vitamins C and E. 5. Cow's milk is too concentrated for an infant's kidneys to manage.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? 1. Vesicular 2. Bronchial 3. Crackles 4. Rhonchi

3. Crackles Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? (Choose all that apply) 1. Tetany 2. Seizures 3. Diarrhea 4. Weakness 5. Dysrhythmias

3. Diarrhea 4. Weakness 5. Dysrhythmias Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.

While performing a physical assessment of a female client, a nurse notices hair on the client's upper lip, chin, and cheeks. Which condition may result in this condition? 1. Aging 2. Poor nutrition 3. Endocrine disease 4. Arterial insufficiency

3. Endocrine disease Endocrine diseases such as hirsutism will result in excessive hair growth on the upper lip, chin, and cheeks. Aging and poor nutrition will result in decreased hair growth. Arterial insufficiency will result in decreased hair growth due to compromised blood supply.

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? 1. Occipital headache 2. Periorbital crepitus 3. Expectoration of blood 4. Changes in vocalization

3. Expectoration of blood After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal resection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However, the sound of the voice is altered temporarily by the presence of nasal packing and edema.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this pulse can be characterized as what? 1. Diminished 2. Normal 3. Full 4. Bounding

3. Full The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected or normal pulse, and a 4+ rating is a bounding pulse.

Which type of breathing pattern alteration is manifested with hypercarbia? 1. Eupnea 2. Tachypnea 3. Hypoventilation 4. Kussmaul's respiration

3. Hypoventilation Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration is interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul's respirations.

The nurse recognizes that a common conflict experienced by older adults is the conflict between what? 1. Youth and old age 2. Retirement and work 3. Independence and dependence 4. Wishing to die and wishing to live

3. Independence and dependence A common conflict confronting older adults is between the desire to be taken care of by others and the desire to be in charge of their own destiny. The conflict between the young and old age may occur but is not common. The conflict between the retirement and working may occur but is not common. The conflict between wishing to die and wishing to live may occur but is not common.

Which finding is inferred from a grade 4 intensity of heart murmurs? 1. Thrill is easily palpable 2. Quiet and clearly audible thrill 3. Loud murmur associated with thrill 4. Moderately loud murmur without thrill

3. Loud murmur associated with thrill Grade 4 indicates loud murmurs with an associated thrill. A thrill is a fine vibration that is felt by palpation. A grade 5 intensity is characterized by an easily palpable thrill. A grade 2 intensity is characterized by quiet and clearly audible murmurs. A moderately loud murmur without a thrill is noted as grade 3.

The nurse is caring for a client with a family history of diabetes mellitus. The client has been following a diet regimen recommended by the dietician and walking for 45 minutes daily for the past eight months. How should the nurse document the client's stage based on the transtheoretical model of health behavior change? 1. Action 2. Preparation 3. Maintenance 4. Contemplation

3. Maintenance The client is in the maintenance stage of human behavior change. During this stage, the client has managed to incorporate the changes in to the lifestyle. This stage begins six months after the action has started and continues indefinitely. The action stage lasts for six months from the time the client has incorporated the changes in to the lifestyle. During the preparation stage, the client begins to realize that the advantages of the change outweigh the disadvantages. The client starts making small changes in preparation for major changes the following month. During the contemplation stage, the client is still considering whether to incorporate changes in the next six months.

Which physical skin finding indicates opioid abuse? 1. Diaphoresis 2. Red, dry skin 3. Needle marks 4. Spider angiomas

3. Needle marks Needle marks of the skin indicate opioid abuse. Diaphoresis indicates sedative hypnotic abuse. Red, dry skin indicates phencyclidine abuse. Spider angiomas indicate alcohol abuse.

The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 1. Multipara in active labor 2. Middle-aged woman with substernal chest pain 3. Older adult male with a partially amputated finger 4. Adolescent boy with an oxygen saturation of 91%

3. Older adult male with a partially amputated finger Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening, and the client can wait for care. A woman in active labor should be assessed immediately, because birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a life-threatening illness and should be assessed immediately.

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present? 1. Headache 2. Pallor 3. Paresthesias 4. Blurred vision

3. Paresthesias Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia

The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care? 1. Meet the clients' family. 2. Read the clients' medical reports. 3. Participate in the bedside rounds. 4. Visit the clients and introduce self.

3. Participate in the bedside rounds.

While assessing an older adult during a regular health checkup, a nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? (Choose all that apply) 1. Presence of hyoid bone damage 2. Presence of cognitive impairment 3. Presence of burns from cigarettes 4. Presence of bed sores. 5. Presence of unexplained bruises on the wrist(s)

3. Presence of burns from cigarettes 4. Presence of bed sores. 5. Presence of unexplained bruises on the wrist(s)

The nurse documents the data gathered during the assessment in a client's medical record. What should the nurse do to ensure that the data is meaningful to other healthcare providers? 1. Record subjective information in own words. 2. Form judgments through written communication. 3. Record objective information using accurate terminology. 4. Compare data from the physical examination with client behavior.

3. Record objective information using accurate terminology. The nurse should document all objective information using accurate terminology. The nurse should pay attention to the facts and report findings exactly as seen, felt, or smelled. If the information is not specific, another healthcare provider reading the data gets only general impressions. The nurse should record subjective information in quotations, exactly as described by the client. The nurse should refrain from generalizing or forming judgments during documentation. This information is used to form nursing diagnoses, which must be factual and accurate. During validation, the nurse compares data from the physical examination with client behavior.

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? (Choose all that apply) 1. Radial pulse: 70 2. Temperature: 37 °C 3. Respiratory rate: 14 4. Blood pressure: 110/70 5. Oxygen saturation: 92%

3. Respiratory rate: 14 4. Blood pressure: 110/70 5. Oxygen saturation: 92%

A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting after eating. These symptoms have lasted 5 days. Upon further assessment, the primary healthcare provider finds that the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food borne disease would be suspected in this client? 1. Listeriosis 2. Shigellosis 3. Salmonellosis 4. Staphylococcus

3. Salmonellosis A client with salmonellosis will experience severe diarrhea, abdominal cramps, and vomiting; these symptoms last as long as 5 days after the intake of contaminated food. This disorder may be caused by Salmonella typhi or Salmonella paratyphi. The causative organism is usually present in such foods as eggs, salad dressings, and sandwich fillings. A client with listeriosis will experience severe diarrhea, fever, headache, pneumonia, meningitis, and endocarditis 3 to 21 days after infection. The symptoms of shigellosis range from cramps and diarrhea to a fatal dysentery that lasts for 3 to 14 days. Pain, vomiting, diarrhea, perspiration, headache, fever, and prostration lasting for 1 or 2 days are the symptoms of a Staphylococcus infection.

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns can be expected in this client? 1. Spoon-shaped nails 2. Transverse depressions in nails 3. Softening of nail beds and flat nails 4. Red or brown linear streaks in nail bed

3. Softening of nail beds and flat nails Softening of the nail bed and enlarged finger tips with flattened nails are signs of clubbing of the nails. Clubbing results in a change of the angle between the nail and nail base, and is seen in conditions of oxygen deficiency, such as in heart or pulmonary diseases. Conditions such as iron deficiency anemia and syphilis cause curvature of nails, which is called koilonychia. Transverse depressions in nails indicate a temporary disturbance of nail growth called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, and trichinosis. They are called splinter hemorrhages.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1. The nurse notes nonverbal signs of discomfort. 2. The nurse observes the client's position in bed. 3. The nurse asks the client to explain the surgery. 4. The nurse asks the client to rate the severity of pain.

3. The nurse asks the client to explain the surgery. The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client's positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.

A nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STI). Which statement of the client indicates effective learning? 1. "I will use condoms when having sex with an infected partner." 2. "I will perform a genital self-examination every month before bathing." 3. "I will refrain from getting the human papilloma virus vaccine (HPV) before the age of 27 years." 4. "I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia."

4. "I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia."

How does the World Health Organization (WHO) define "health"? 1. A condition when people are free of disease 2. A condition of life rather than pathological state 3. An actualization of inherent and acquired human potential 4. A state of complete physical, mental, and social well-being

4. A state of complete physical, mental, and social well-being

What clinical finding indicates to the nurse that a client may have hypokalemia? 1. Edema 2. Muscle spasms 3. Kussmaul breathing 4. Abdominal distention

4. Abdominal distention Hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a sign of hypocalcemia. Kussmaul breathing is a sign of metabolic acidosis.

Which physical assessment technique involves listening to the sounds of the body? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

4. Auscultation

A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost the perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been injured in this client? 1. Cranial nerve X 2. Cranial nerve IX 3. Cranial nerve XII 4. Cranial nerve VII

4. Cranial nerve VII Cranial nerve VII is the facial nerve. Injury to the facial nerve limits the sensory impulses from the anterior two-thirds of the tongue, along with altered facial expressions. Cranial nerve X is the vagus nerve, injury to which causes limitation of palatal movements. Cranial nerve IX is the glossopharyngeal nerve. Injury to this nerve results in loss of taste impulses from the posterior one-third of the tongue. Cranial nerve XII is the hypoglossal nerve, damage of which results in improper movements of the tongue.

An elderly client is admitted to the healthcare facility following a stroke. What should the nurse do when the client's relative who arrived much later asks to see the client's health record? 1. Confirm the client's relationship first. 2. Ask the client's primary healthcare provider. 3. Inform the nurse manager and show the records. 4. Explain that medical health records are confidential.

4. Explain that medical health records are confidential.

A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate? 1. Ulnar 2. Radial 3. Brachial 4. Femoral

4. Femoral because other pulses may not be palpable at this time. The ulnar site is used to assess the status of circulation to the hand and also used to perform the Allen test. The radial site is commonly used to assess the character of the pulse peripherally and to assess the status of the circulation to the hand. The brachial site is used to assess the status of the circulation to the client's lower arm or the blood pressure is being auscultated.

The nurse is performing a weight assessment for different people in a community. Which question should the nurse ask a client to determine a disease-related change in weight? 1. Do you follow a strict calorie intake? 2. Have you notices any changes in the social aspects of eating? 3. Are you taking diuretics or insulin? 4. Have you noticed any unintentional weight loss in the past six months?

4. Have you noticed any unintentional weight loss in the past six months?

The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format? 1. NANDA-I label, related factor, and etiologies 2. NANDA-I label, risk factor, and nursing interventions 3. NANDA-I label, related factor, and nursing interventions 4. NANDA-I label, related factor, and defining characteristics

4. NANDA-I label, related factor, and defining characteristics

While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding? 1. There is absence of a pulse. 2. The pulse strength is normal. 3. The pulse strength is bounding. 4. The pulse strength is barely palpable.

4. The pulse strength is barely palpable. A pulse strength of 1+ indicates a diminished or barely palpable pulse and requires immediate intervention. Absence of pulse is documented as 0. Normal pulse strength is documented as 2+. If the pulse strength is bounding, then it is documented as 4+.

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 109o F. Convert this temperature into Celsius and record your number using one decimal place.

42.8 C

Which physical assessment of the skin indicates that a client is addicted to phencyclidine? 1. Burns 2. Vasculitis 3. Diaphoresis 4. Red and dry skin

4. Red and dry skin Red and dry skin is associated with phencyclidine abuse. A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse. Diaphoresis is associated with chronic abuse of sedative hypnotics.

The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressure. What is the most important nursing intervention for this client? 1. Educate the client on managing stress. 2. Teach the client to maintain a balanced diet. 3. Instruct the client to have regular health checkups. 4. Ask the client to use sunscreen when working outdoors.

1. Educate the client on managing stress.

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1. Crackles in the lungs 2. Decreased heart rate 3. Decreased blood pressure 4. Cyanosis

1. Crackles in the lungs Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.

A registered nurse is teaching a nursing student about when a client with high blood pressure should follow up with the primary healthcare provider. Which statement made by the nursing student indicates effective learning? 1. "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year." 2. "I will advise a client with a blood pressure of 110/70 mm Hg to follow up in a year." 3. "I will advise a client with a blood pressure of 150/90 mm Hg to follow up in a month." 4. "I will advise a client with a blood pressure of 185/115 mm Hg to follow up in a month."

1. "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year."

A nurse is teaching a client about measures to promote health. Which statements made by the client indicate effective learning? 1. "I will assess my own pulse rate after exercising." 2. "I will follow my hypertension treatment plan consistently." 3. "I will recalibrate my aneroid sphygmomanometer once a year." 4. "I will perform a self-assessment of my heart rate using the carotid pulse." 5. "I will ask my caretaker to check my blood pressure at a different time every day."

1. "I will assess my own pulse rate after exercising." 2. "I will follow my hypertension treatment plan consistently." 4. "I will perform a self-assessment of my heart rate using the carotid pulse."

A client presents with a shiny appearance of abdominal skin. The skin also has a taut appearance. Which condition may the client have? 1. Ascites 2. Cyanosis 3. Accidental injury 4. Bleeding disorder

1. Ascites Symptoms of ascites include a shiny and taut appearance of the abdominal skin. Cyanosis occurs when there is a bluish discoloration of the skin. Accidental injury and different types of bleeding disorders are characterized by bruises or needle marks on the skin.

The findings of four clients who underwent eye examinations are given below. Which client is suspected to have sustained injury to the cranial nerve III? 1. Client A: drooping eyelids 2. Client B: near sightedness 3. Client C: Cross eyes 4. Client D: Protruding eyes

1. Client A: drooping eyelids Injury to the third cranial nerve may result in edema or impairment of the third cranial nerve. This results in the abnormal drooping of the eyelids, a condition called ptosis. Myopia is nearsightedness, a refractive error in which rays of light enter the eye and focus in front of the retina. Cross-eyes result from strabismus, which results from neuromuscular injury or congenital anomaly. Protruding eyes (exophthalmoses) is indicative of hyperthyroidism.

A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are the expected errors in the obtained readings? 1. False high reading 2. False low diastolic reading 3. False high systolic reading 4. False high diastolic reading

1. False high reading If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome is a false high reading. Application of the stethoscope too firmly against antecubital fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too often result in a false high systolic reading. Deflating the cuff too slowly results in a false high diastolic reading.

What are the benefits of using standard formal nursing diagnostic statements? (Choose all that apply) 1. Fosters development of nursing knowledge 2. Allows nurses to communicate with the client 3. Provides precise definition of the client's problem 4. Distinguishes the nurse's role from that of other care providers 5. Enables the primary healthcare provider to deliver effective health care

1. Fosters development of nursing knowledge 3. Provides precise definition of the client's problem 4. Distinguishes the nurse's role from that of other care providers

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

1. Planning

While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate? 1. Relapsing 2. Sustained 3. Remittent 4. Intermittent

1. Relapsing Periods of febrile episodes coupled with periods of acceptable temperature values is a relapsing type of fever. These periods are often longer than 24 hours. In a sustained fever, the body temperature remains constantly above 38 oC with little fluctuations. In a remittent fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in 24 hours, the fever is termed intermittent.

What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique? 1. "Effectiveness depends on the child's age." 2. "Spanking is strongly suggestive of negative role behavior." 3. "Spanking may be the only option when no other technique works." 4. "Research studies have shown it to be an effective disciplinary technique."

2. "Spanking is strongly suggestive of negative role behavior."

The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action? 1. Cranial nerve II 2. Cranial nerve XI 3. Cranial nerve VI 4. Cranial nerve VII

2. Cranial nerve XI Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of head and shoulders. Cranial nerve II (optic nerve) is a sensory nerve for visual acuity. Cranial nerve VI (abducens nerve) is a motor nerve that coordinates the lateral movement of eyeballs. Cranial nerve VII or (auditory nerve) is a sensory nerve which coordinates the hearing sense.

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness? 1. Applying moisturizing lotion between toes 2. Cutting nails after soaking them for 10 minutes in warm water 3. Cutting nails straight across and even with the tops of the fingers or toes 4. Using sharp objects to poke or dig under the toenail or around the cuticle

2. Cutting nails after soaking them for 10 minutes in warm water

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? (Choose all that apply) 1. Axilla 2. Fingers 3.Ear lobes 4. Forehead 5. Upper thorax

2. Fingers 3.Ear lobes Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.

Which client assessment finding should the nurse document as subjective data? 1. Blood pressure 120/82 beats/min 2. Pain rating of 5 3. Potassium 4.0 mEq 4. Pulse oximetry reading of 96%

2. Pain rating of 5

Following assessment, a nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. What would be the cause of these sounds? 1. Parietal pleura rubbing against visceral pleura 2. Random, sudden reinflation of groups of alveoli 3. Turbulence due to muscular spasm and fluid or mucus in the larger airways 4. High-velocity airflow through severely narrowed or an obstructed airway

3. Turbulence due to muscular spasm and fluid or mucus in the larger airways Loud, low pitched, rumbling coarse sounds heard over the trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucous is present in the larger airways. Pleural rub produces a dry or grating quality sound, best heard in the lower portion of the anterior lateral lung. Random and sudden reinflation of groups of alveoli produces crackling sounds predominantly heard in the left and right lung bases. High-velocity airflow through severely narrowed or obstructed airways results in a wheezing sound heard all over the lung.

While assessing a client who sustained a road traffic accident, a nurse notices that the client is unable to clench his teeth. Which cranial nerve might have been affected? 1. Facial nerve 2. Trochlear nerve 3. Abducens nerve 4. Trigeminal nerve

4. Trigeminal nerve The trigeminal nerve provides sensory innervation to the facial skin and motor innervation to the muscles of the jaw. A client with a damaged trigeminal nerve will be unable to clench his teeth. The facial nerve provides sensory and motor innervations for facial expressions. The trochlear nerve is involved in downward and inward eye movements. The abducens nerve helps in the eyeball's lateral movement.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? 1. Stage I 2. Stage II 3. Stage III 4. Unstageable

4. Unstageable A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full-thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.