A nurse is assessing the sacral area of a client who has been on bed rest for several days. The nurse notes intact skin with localized redness that does not blanch when pressure is applied. How should the nurse document this finding?"
Deep tissue pressure injury
Skin tear
Stage 1 pressure injury
Stage 2 pressure injury
The Correct Answer is C
Rationale:
A. A deep tissue pressure injury involves intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, or purple discoloration, often resulting from underlying soft tissue damage. In this case, the redness is superficial, localized, and the skin is intact, so it does not meet the criteria for a deep tissue injury.
B. A skin tear is a traumatic wound caused by friction or shear, resulting in partial or full separation of the skin layers. This client’s skin is intact with redness and no tearing, so it is not a skin tear.
C. Stage 1 pressure injury is characterized by intact skin with non-blanchable redness over a bony prominence. This aligns exactly with the nurse’s observation: the sacral skin is intact, and redness does not blanch when pressure is applied. Stage 1 is considered the earliest recognizable stage of pressure injury and requires preventive interventions to avoid progression.
D. Stage 2 pressure injury involves partial-thickness skin loss with exposed dermis, which may appear as a shallow open ulcer or blister. Since this client’s skin remains intact, the finding does not meet the criteria for stage 2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. The femoral triangle, located in the upper thigh near the inguinal ligament, is where the femoral artery runs and is palpated for the femoral pulse. It does not provide information about distal lower extremity circulation, so it is not used to assess the posterior tibial pulse.
B. The knee area corresponds to the popliteal artery, which is palpated behind the knee for the popliteal pulse. This site is deeper and more difficult to palpate, and it does not reflect circulation in the foot or ankle.
C. The posterior tibial pulse is located on the postero-medial aspect of the lower third of the leg, just behind the medial malleolus. Palpating here allows assessment of arterial blood flow to the foot and helps detect peripheral arterial disease in the lower extremities.
D. The area between the second and third toes is where the dorsalis pedis artery runs. Palpating this site assesses the dorsalis pedis pulse, not the posterior tibial pulse, and evaluates a different part of foot circulation.
Correct Answer is C
Explanation
Rationale:
A. Decreased serum calcium affects bone health and may lead to osteoporosis or muscle weakness, but it is not a direct factor in the development of pressure injuries. While poor calcium levels may indirectly affect mobility, pressure injuries are primarily caused by localized tissue ischemia rather than systemic calcium deficiencies.
B. Increased muscle mass actually provides more padding over bony prominences, which helps protect against pressure injury. Clients with well-developed musculature are generally at lower risk compared with those who have muscle wasting or atrophy.
C. Decreased circulation is a primary risk factor for pressure injury development. Impaired blood flow reduces oxygen and nutrient delivery to tissues, making skin and subcutaneous tissue more susceptible to ischemia and necrosis when exposed to prolonged pressure, friction, or shear. Clients with impaired mobility are especially vulnerable because they cannot shift positions effectively to relieve pressure.
D. Increased collagen strengthens connective tissue and promotes skin integrity. While insufficient or abnormal collagen can contribute to skin breakdown, increased collagen alone does not predispose a client to pressure injuries and is generally protective rather than harmful.
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.