A nurse is assessing a client's coccyx area and notes visible subcutaneous fat with tunneling. Which of the following pressure injury stages should the nurse document?
Unstageable
Stage 2
Stage 3
Stage 4
The Correct Answer is C
A. Unstageable: An unstageable pressure injury occurs when the full thickness of tissue loss is obscured by slough or eschar. Since subcutaneous fat and tunneling are visible in this case, the injury can be staged and is not unstageable.
B. Stage 2: Stage 2 pressure injuries involve partial-thickness skin loss with exposed dermis. They do not extend into subcutaneous tissue and do not present with tunneling or visible fat, so this stage does not fit the description.
C. Stage 3: A Stage 3 pressure injury involves full-thickness skin loss. At this stage, subcutaneous fat (adipose tissue) is visible within the ulcer. Features like tunneling (a narrow opening or passageway extending from the wound) and undermining (tissue destruction underneath the intact skin at the wound edge) are common. However, the nurse should not be able to see bone, tendon, or muscle; if these deeper structures were visible, the injury would be classified as Stage 4.
D. Stage 4: A Stage 4 pressure injury involves full-thickness skin and tissue loss. The distinguishing factor for Stage 4 is the direct visualization or palpation of fascia, muscle, tendon, ligament, cartilage, or bone within the ulcer. While tunneling can occur in Stage 4, the presence of only subcutaneous fat keeps this specific injury at Stage 3.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Slurred speech: Slurred speech is typically associated with intoxication from central nervous system depressants, such as alcohol or opioids, rather than withdrawal. During withdrawal, the client is more likely to exhibit hyperactive or restless behavior.
B. Constricted pupils: Pupillary constriction (miosis) occurs with opioid intoxication. In contrast, opioid withdrawal usually causes dilated pupils (mydriasis) due to sympathetic nervous system overactivity.
C. Sedation: Sedation is a common effect of opioid use, not withdrawal. During withdrawal, clients are generally hyperalert, restless, and may experience insomnia rather than excessive sleepiness.
D. Yawning: Yawning is a classic sign of opioid withdrawal and reflects autonomic nervous system activation. It is often accompanied by lacrimation, rhinorrhea, sweating, and other early withdrawal symptoms.
Correct Answer is D
Explanation
A. A cervical cap is recommended for clients who have an abnormal Papanicolaou (Pap) test: A cervical cap is not recommended for clients with abnormal Pap results because it may irritate the cervix or complicate follow-up care. Clients should wait until any cervical abnormalities are resolved before using this method.
B. Hormonal contraceptive methods decrease the client's risk for hypertension: Hormonal contraceptives, particularly those containing estrogen, can actually increase the risk of hypertension and thromboembolic events in some clients, rather than reduce it. Blood pressure monitoring is recommended during use.
C. Fertility awareness-based methods are more effective than hormonal methods: Fertility awareness methods generally have higher failure rates compared to hormonal contraceptives. Hormonal methods provide more reliable pregnancy prevention when used correctly.
D. Barrier methods can be used by clients who are breastfeeding: Barrier methods, such as condoms, diaphragms, and cervical caps, are safe for breastfeeding clients because they do not affect milk production or hormone levels. They provide effective contraception without interfering with lactation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.