A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?
Slough tissue is present.
Adipose tissue is present.
Fascia tissue is present.
Undermining is present.
The Correct Answer is C
A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.
B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.
C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.
D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer an antibiotic. While antibiotics may be needed, they must be ordered by the provider. The nurse should notify the provider first to evaluate for infection.
B. Provide a warm water soak to the area. Warm soaks can worsen infection by promoting bacterial growth.
C. Provide education about pain management. While pain management education is important, the wound findings (purulent drainage, warmth, erythema) suggest possible infection, which requires medical intervention first.
D. Notify the provider about the findings. Signs of infection (erythema, warmth, purulent drainage) need to be reported immediately for further evaluation and treatment (e.g., wound culture, antibiotics).
Correct Answer is C
Explanation
A. "Tell me about your support system at home." This is an open-ended, therapeutic question that encourages the patient to discuss their support network.
B. "What treatment options has your doctor spoken with you about?" This is an appropriate way to assess the patient's understanding of their diagnosis and plan of care.
C. “I am sure you are scared. Everything will be okay." This statement is nontherapeutic because it offers false reassurance and dismisses the patient’s emotions rather than acknowledging their concerns.
D. "This must be a hard time for you. How are you coping?" This is an empathetic statement that acknowledges the patient's feelings and invites them to express their emotions.
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