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A nurse is attending to a patient who is unable to move.
Which stage of pressure injuries is most likely indicated by the presence of non-blanchable erythema on the patient’s heels?

A.

Stage I pressure injury.

B.

Stage II pressure injury.

C.

Stage III pressure injury.

D.

Stage IV pressure injury.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Stage I pressure injury is characterized by non-blanchable erythema of intact skin. This means that the skin does not turn white when pressed and is a sign of damage to the underlying

tissues. This stage is often seen in areas of the body that are under constant pressure, such as the heels in a patient who is unable to move.

Choice B rationale

Stage II pressure injury involves partial-thickness loss of skin with exposed dermis. This stage is more severe than stage I and would present with an open wound, which is not described in the question.

Choice C rationale

Stage III pressure injury involves full-thickness loss of skin, in which fatty tissue is visible in the wound. This stage is more severe than both stages I and II and would present with a deeper wound, which is not described in the question.

Choice D rationale

Stage IV pressure injury involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. This is the most severe stage of pressure injury and would present with a very deep wound exposing underlying structures, which is not described in the question.


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Related Questions

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Action

Essential

Nonessential

Contraindicated

Increasing IV fluid rate

The current rate is prescribed by the provider; increasing it without further assessment could lead to complications.

Encouraging the client to sit up without assistance

The client feels faint upon sitting up and is unsteady, so this could be dangerous.

Administering antiemetic medication

Helpful but not immediately critical.

Monitoring respiratory rate closely

Crucial due to client's rapid breathing and anxiety.

Providing reassurance and calming interventions

Important due to client's anxiety and discomfort.

Checking electrolyte levels regularly

Essential for ongoing monitoring given the client's symptoms.

Essential

  1. Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.

  2. Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.

  3. Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

  1. Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

  1. Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.

  2. Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.

Correct Answer is A

Explanation

Choice A rationale

Spending time with the patient is a therapeutic nursing approach when caring for a patient hospitalized for the treatment of severe depression. This approach shows the patient that they

are not alone and that their feelings are important. It can help build trust and rapport, which are essential for effective therapeutic communication and intervention.

Choice B rationale

Offering the patient choices of activities can be beneficial as it can provide a sense of control and improve mood. However, this approach should be used judiciously as the patient’s energy levels and interest in activities may be low due to depression.

Choice C rationale

Establishing a therapeutic relationship with the patient is an important aspect of care. However, this is a broad approach and involves more than just spending time with the patient. It includes building trust, maintaining confidentiality, and providing empathetic and nonjudgmental care.

Choice D rationale

Exploring the truth of the patient’s statements can be part of cognitive behavioral therapy (CBT), a common treatment for depression. However, this is usually done by a trained therapist and not by a nurse providing general care.

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