A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?
stage I
stage II
stage III
stage IV
stage IV
The Correct Answer is D
The correct answer is choice D. The description of full-thickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer indicates a pressure ulcer that is categorized as stage IV. In this stage, the ulcer is characterized by fullthickness tissue loss, exposing muscle, bone, or tendons. Stage I (choice A) pressure injuries involve non-blanchable erythema of intact skin. Stage II (choice B) pressure injuries involve partial-thickness skin loss, which can involve the epidermis, dermis, or both. Stage III (choice C) pressure injuries involve fullthickness tissue loss, but not bone, tendon, or muscle. Therefore, based on the description provided, the pressure ulcer is categorized as stage IV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The PCA (patient-controlled analgesia) pump is programmed to deliver a dose of 0.5 mg of morphine every 15 minutes as needed. This setup means that only 1 dose can be administered every 15 minutes, regardless of how many times the patient presses the button.
Since 60 minutes have passed, the maximum number of doses the patient could receive is calculated as follows:
60 minutes/ 15 minutes per dose= 4 doses
Even though the patient pressed the button 10 times, the pump will only deliver a dose every 15 minutes, resulting in 4 doses.
Correct Answer is C
Explanation
The correct answer is choice C: "The doctors must have made a mistake." KüblerRoss defines five stages of psychosocial responses to dying and death: denial, anger, bargaining, depression, and acceptance. Denial is the first stage, characterized by a refusal to accept the reality of the situation. In this stage, individuals may use defense mechanisms to cope with the overwhelming emotions associated with their diagnosis or prognosis. The statement "The doctors must have made a mistake" is an example of denial as the individual refuses to accept the diagnosis and instead attributes it to an error by medical professionals.
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