A client with a pressure ulcer reports partial-thickness skin loss involving the epidermis and/or dermis.
Which symptom should the nurse expect to find during the assessment?
"I have a wound that is cold to the touch.".
"The area around the wound is red.".
"I feel tenderness when touching the wound.".
"My wound is deep, down to the muscle.".
The Correct Answer is C
Choice A rationale:
Coldness to the touch is not a characteristic symptom of partial-thickness skin loss involving the epidermis and/or dermis.
This symptom is more indicative of compromised blood flow, such as in arterial insufficiency, and is not specific to pressure ulcers.
Choice B rationale:
Redness around the wound is a characteristic symptom of partial-thickness skin loss (stage 2 pressure ulcer).
This redness is due to localized inflammation and represents damage to the epidermis and/or dermis, but it does not involve muscle or deeper tissues.
Choice C rationale:
Tenderness when touching the wound is an expected symptom in partial-thickness skin loss involving the epidermis and/or dermis (stage 2 pressure ulcer).
The presence of tenderness is indicative of ongoing tissue damage and inflammation in the affected area.
Choice D rationale:
The statement, "My wound is deep, down to the muscle," suggests a full-thickness wound (stage 3 or 4 pressure ulcer) where muscle and deeper tissues are involved.
This statement does not align with the description provided in the question, which specifies partial-thickness skin loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Consulting with the healthcare team to address underlying medical conditions (Choice A) is the most appropriate nursing action for a client with a pressure ulcer and signs of infection.
Pressure ulcers can develop or worsen due to underlying medical conditions such as diabetes, vascular disease, or immunosuppression.
Addressing these underlying conditions is essential for effective wound management and preventing further complications.
Choice B rationale:
Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention to prevent pressure ulcers, but in a client with an existing pressure ulcer and signs of infection, addressing the infection and underlying medical conditions take precedence.
Choice C rationale:
Using specialized mattresses to offload pressure (Choice C) is an important part of pressure ulcer prevention and management, but it may not be the most immediate action needed for a client with signs of infection.
Addressing infection and underlying medical conditions (Choice A) should be the priority.
Choice D rationale:
Providing education on proper wound care and prevention strategies (Choice D) is an essential nursing action but may not be the most immediate priority for a client with an active infection.
Managing the infection and addressing underlying medical conditions (Choice A) should come first.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
The wound's warmth to the touch is not a primary factor to consider when selecting a dressing for a pressure ulcer.
The choice of dressing should primarily be based on the wound's characteristics, such as its depth, exudate level, and tissue involvement.
Choice B rationale:
The presence of a foul odor from the wound is an important factor to consider when selecting a dressing.
Malodorous wounds may indicate infection or necrotic tissue, and appropriate wound dressings can help manage odor and promote healing.
Choice C rationale:
The extent of tissue damage, including muscle and bone involvement, is a critical factor in choosing an appropriate dressing for a pressure ulcer.
Dressings should be selected based on the depth of the wound and the extent of tissue damage to support healing and prevent complications.
Choice D rationale:
The patient's mobility and pressure on vulnerable areas are essential considerations when selecting a dressing.
Dressings should help offload pressure from vulnerable areas and promote mobility while providing optimal wound care.
The choice of dressing should support the overall management of the patient's condition.
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