A nurse is assessing a client with a skin condition. Which of the following describes the client’s condition?
Full thickness skin loss with visible bone.
Intact skin with localized erythema.
Partial-thickness skin loss with red tissue.
Full thickness skin loss with visible adipose tissue.
The Correct Answer is D
Choice A rationale
Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.
Choice B rationale
Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Choice C rationale
Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
Choice D rationale
Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Chilling the irrigant prior to the procedure is not recommended. Cold irrigant can cause discomfort and potentially lead to vasoconstriction, which can impede the healing process.
Choice B rationale
Irrigating the wound until the solution that is draining is clean is a standard practice in wound care. This helps to ensure that all debris and potential contaminants are removed from the wound.
Choice C rationale
Holding the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating is not a standard practice. The syringe should be held close to the wound to ensure effective irrigation.
Choice D rationale
Flushing the wound from the most contaminated area to the cleanest area is not a standard practice. The wound should be irrigated from the cleanest to the dirtiest area to prevent the spread of contamination.
Correct Answer is C
Explanation
Choice A rationale
Detecting the scent of a rose is primarily associated with the olfactory system, not the tactile system.
Choice B rationale
Observing the color of a flower is primarily associated with the visual system, not the tactile system.
Choice C rationale
Feeling the texture of a fabric is primarily associated with the tactile system. The tactile system, part of the somatosensory system, allows us to perceive touch, pressure, temperature, pain, and vibration.
Choice D rationale
Hearing the sound of a bell is primarily associated with the auditory system, not the tactile system.
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