A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Thick, dry, and dark area on bilateral heels.

Broken skin without evidence of undermining.

Defined area of persistent redness over bone.

Superficial sacral ulcer with defined margins.

Answer and Explanation

The Correct Answer is C

Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.

Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.

Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.

Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.

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Correct Answer is D

Explanation

Choice A reason: Sudden swelling, redness, warmth, and pain are more indicative of acute conditions like deep vein thrombosis rather than chronic arterial symptoms.

Choice B reason: Weeping ulcers on lower legs are more commonly associated with venous insufficiency rather than arterial disease.

Choice C reason: Ankle edema and varicose veins are typically associated with venous disorders, not arterial disease.

Choice D reason: Intermittent claudication, which is pain during walking that subsides with rest, is a hallmark of peripheral arterial disease and is an expected finding in clients with this condition.

A. Initiate teaching for client care after discharge. B. Evaluate and update plans of care for clients. C. Begin initial sterile wound care for surgical clients. D. Validate prescribed intravenous flow rates.

Correct Answer is D

Explanation

Choice A reason: Teaching for client care after discharge often involves patient education and planning, which are complex tasks typically reserved for registered nurses due to their scope of practice.

Choice B reason: Evaluating and updating plans of care are responsibilities that involve clinical judgment and are usually performed by registered nurses.

Choice C reason: Initial sterile wound care may require assessment and decision-making that are within the registered nurse's scope of practice.

Choice D reason: Validating prescribed intravenous flow rates is a task that can be delegated to a practical nurse, as it involves monitoring and ensuring that the flow rates are set according to the prescribed orders, which is within the practical nurse's scope of practice.

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A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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