A clinical instructor is discussing pressure injuries during post-conference. Which statement by the student nurse indicates understanding of a pressure injury?
"Localized damage to the skin and underlying tissue usually found over a bony prominence,"
"Separation of wound layers as a result of excessive stress."
"A collection of infected fluid that has not drained and interrupts wound healing."
"Internal bleeding under the skin layers that causes skin breakdown."
The Correct Answer is A
A. "Localized damage to the skin and underlying tissue usually found over a bony prominence": Pressure injuries, also known as pressure ulcers or decubitus ulcers, result from prolonged pressure that exceeds capillary perfusion pressure, causing ischemia and tissue necrosis. They commonly occur over bony prominences such as the sacrum, heels, elbows, and occiput where soft tissue is compressed between bone and an external surface.
B. "Separation of wound layers as a result of excessive stress": This description refers to wound dehiscence, a surgical complication where previously approximated tissue layers reopen, often due to mechanical stress, infection, or poor healing. While wound dehiscence involves tissue disruption, it is not related to pressure-induced ischemic injury.
C. "A collection of infected fluid that has not drained and interrupts wound healing": This describes an abscess, which is a localized collection of pus caused by infection. Abscess formation is inflammatory and infectious in nature, rather than the ischemic tissue damage caused by prolonged pressure. Pressure injuries may however become secondarily infected.
D. "Internal bleeding under the skin layers that causes skin breakdown": This describes a hematoma, which is a localized collection of blood within tissue due to vessel rupture. Hematomas can contribute to tissue compromise but are distinct from pressure injuries, as pressure injuries result from sustained external compression leading to ischemia, not trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ask the patient to sit about 4 ft away facing the nurse: The assessment of extraocular movements (EOM) requires close observation of the patient’s eye tracking and alignment. Sitting too far away, such as 4 feet, may make it difficult to accurately detect subtle deviations, nystagmus, or limitations in gaze. Proper assessment distance is usually around 12–24 inches.
B. Use a penlight approximately 1 ft away from the patient's face and move it slowly in all 6 directions: This technique aligns with the standard EOM assessment. The nurse instructs the patient to follow a target (penlight or finger) through the six cardinal positions of gaze: up, down, left, right, and diagonals. Moving the target slowly allows for observation of smooth pursuit, symmetry, and potential deficits in cranial nerves III, IV, and VI.
C. Ask the patient to cover one eye with their hand: Covering one eye is part of the cover-uncover test, which assesses for strabismus or phorias, not general EOM. While it can provide information on ocular alignment, it does not evaluate full extraocular muscle function through the six cardinal positions of gaze.
D. Move a penlight in a circular motion 1 ft away in front of the patient's eyes: Moving the penlight in a circular motion is not appropriate for EOM assessment, as it does not systematically test each extraocular muscle or cranial nerve. Circular motion may obscure deficits in specific directions of gaze and can result in incomplete assessment of ocular motor function.
Correct Answer is C
Explanation
A. "I've given her some medication; please report to me whether it seems to have relieved her pain within an hour or so.": NAP are not responsible for evaluating the effectiveness of analgesics, as this requires clinical judgment and assessment skills within the nurse’s scope of practice. Subjective impressions may lead to inaccurate conclusions about pain control.
B. "Be sure to keep the room temperature high and the TV on at all times.": Environmental measures alone are not sufficient for pain management and do not address the primary responsibility of NAP in monitoring patient responses. Maintaining comfort is important, but instructions must be clinically relevant to pain assessment and communication.
C. "Be sure to tell me if you assess an increase in pain, grimacing, or any unusual behavior.": NAP can observe and report nonverbal signs of pain or changes in behavior, which are critical for ongoing assessment. Prompt reporting enables the nurse to intervene appropriately, such as administering medication or implementing additional comfort measures.
D. "Let me know at least 30 minutes before you transport her so I can administer her analgesics.": While coordinating analgesic administration with planned activities is important, this instruction focuses on timing rather than the NAP’s role in monitoring or reporting pain. NAP should observe and communicate changes in pain rather than determine when to medicate.
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