ANSWERS 100% CORRECT
The nurse is performing an assessment on an older adult client. Which assessment data would
indicate a potential complication associated with the skin?
A. Crusting
B. Wrinkling
C. Deepening of expression lines
D. Thinning and loss of elasticity in the skin - ANSWER - A. Crusting
Wrinkling, deepening of expression lines, and thinning and loss of elasticity in the skin are are
considered normal changes of aging. Crusting is concerning for a pathological condition.
A patient's documentation indicates he has a stage III pressure ulcer on his right hip. What
should the nurse expect to find on assessment of the patient's right hip?
A. Exposed bone, tendon, or muscle
B. An abrasion, blister, or shallow crater
C. Deep crater through subcutaneous tissue to fascia
D. Persistent redness (or bluish color in darker skin tones) - ANSWER - C. Deep crater through
subcutaneous tissue to fascia
A stage III pressure injury involves full thickness skin loss or necrosis of the subcutaneous
tissue that may extend down to but not through the underlying fascia
A. Stage IV
B. Stage II
C. Stage III
D. Stage I
Which patient is at the greatest risk for developing pressure ulcers?
A. A 42-year old obese woman with type 2 diabetes
, B. A 78-year old man who is confused and malnourished
C. An 80-year old man who is comatose following a head injury
D. A 65-year old woman who has urge and stress incontinence - ANSWER - C. An 80-year old
man who is comatose following a head injury
Although diabetes, malnutrition, and incontinence can increase risk of pressure injuries, an
elderly patient, immobilized in an intensive care unit is at the highest risk.
The patient is transferring from another facility with the description of a sore on her sacrum that
is deep enough to see the muscle. What stage of pressure ulcers does the nurse expect to see
on admission?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV - ANSWER - D. Stage IV
A stage IV pressure injury involves full-tissue skin loss with destruction extending to muscle,
bone, or supporting structures
The nurse reviews information collected after completing a comprehensive assessment with an
older person. For which reason should the nurse recommend lipid-disorder screening for this
patient?
A. Over the age of 65
B. Body mass index 28.5
C. Blood pressure 140/90 mm Hg
D. Diagnosed with peripheral-artery disease - ANSWER - D. Diagnosed with peripheral-artery
disease
An 80 year old has been admitted to the hospital after a fall. The nurse plans to review the older
adult's mobility status. Order the steps for this encounter:
A. Evaluate the interventions utilized during the encounter
B. Obtain a Hendrich II score
C. Provide proper footwear if ambulating
D. Assess the patient's range of motion and environment - ANSWER - D. Assess the patient's
range of motion and environment