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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Applies non-skid socks before getting the patient out of bed: Non-skid socks help prevent slipping and are an appropriate fall precaution.

B. Activates the chair alarm when the patient is sitting in the chair: Chair alarms alert staff if the patient attempts to get up unassisted, reducing fall risk.

C. Ensures that the bed is in the lowest position prior to leaving the room: Keeping the bed low reduces the severity of injury in case of a fall.

D. Places the patient on bed rest: Bed rest is not a standard fall precaution unless medically necessary. It can lead to deconditioning and further weakness, increasing fall risk.

A. 46-year-old with a low neutrophil count B. 59-year-old seven days post abdominal surgery C. 82-year-old with a history of leukemia ten years ago D. 62-year-old on antibiotic therapy

Correct Answer is A

Explanation

A. 46-year-old with a low neutrophil count: Neutrophils are essential for fighting infection. A low neutrophil count (neutropenia) significantly increases infection risk, making this the highest-priority patient.

B. 59-year-old seven days post abdominal surgery: While postoperative patients are at risk for infection, the greatest risk is within the first few days after surgery. By day seven, the risk decreases if no signs of infection are present.

C. 82-year-old with a history of leukemia ten years ago: While leukemia can affect the immune system, a history of leukemia from ten years ago is less concerning than an active condition causing immunosuppression.

D. 62-year-old on antibiotic therapy: While antibiotics can disrupt normal flora and increase the risk of infections like Clostridioides difficile, this risk is lower than that of a patient with neutropenia.

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A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

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Naxlex Comprehensive Predictor Exams

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