A nurse is caring for a patient with a pressure ulcer that presents as non-blanchable erythema with intact skin.
What clinical manifestation is the nurse likely to observe in this patient?
"My wound is warm to the touch.".
"I have an open wound with pus.".
"I feel a sharp pain in the affected area.".
"There's swelling around the wound.".
The Correct Answer is A
Choice A rationale:
The nurse is likely to observe warmth around the pressure ulcer site with intact skin.
This is a characteristic clinical manifestation of a stage 1 pressure ulcer.
In stage 1 pressure ulcers, there is non-blanchable erythema (redness) of the skin due to localized inflammation, and the area may feel warm to the touch.
However, the skin is still intact, and there are no open wounds or pus.
Choice B rationale:
This choice is incorrect because the patient described in the question has intact skin, and there is no mention of an open wound with pus.
Pus is typically associated with wound infection, which is not a feature of stage 1 pressure ulcers.
Choice C rationale:
The patient reporting a sharp pain in the affected area is not consistent with the characteristics of a stage 1 pressure ulcer.
Stage 1 pressure ulcers are typically not associated with pain because they only involve the superficial layers of the skin, and the underlying tissues are not affected.
Choice D rationale:
Swelling around the wound is not a typical clinical manifestation of a stage 1 pressure ulcer.
In stage 1, the skin may appear red and feel warm to the touch due to inflammation, but there is no mention of swelling in the question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
The wound's warmth to the touch is not a primary factor to consider when selecting a dressing for a pressure ulcer.
The choice of dressing should primarily be based on the wound's characteristics, such as its depth, exudate level, and tissue involvement.
Choice B rationale:
The presence of a foul odor from the wound is an important factor to consider when selecting a dressing.
Malodorous wounds may indicate infection or necrotic tissue, and appropriate wound dressings can help manage odor and promote healing.
Choice C rationale:
The extent of tissue damage, including muscle and bone involvement, is a critical factor in choosing an appropriate dressing for a pressure ulcer.
Dressings should be selected based on the depth of the wound and the extent of tissue damage to support healing and prevent complications.
Choice D rationale:
The patient's mobility and pressure on vulnerable areas are essential considerations when selecting a dressing.
Dressings should help offload pressure from vulnerable areas and promote mobility while providing optimal wound care.
The choice of dressing should support the overall management of the patient's condition.
Correct Answer is B
Explanation
Choice A rationale:
Informing the client that surgery will not be needed for their severe pressure ulcer is not accurate and does not provide the necessary information for the client.
Surgical intervention may be required for severe pressure ulcers, especially when conservative treatments have been unsuccessful.
Choice B rationale:
Educating the client that surgery may involve removing damaged tissue is an important aspect of preparing them for potential surgical intervention.
Surgical debridement may be necessary to remove necrotic or infected tissue and promote wound healing.
Choice C rationale:
Informing the client that they'll need antibiotics after surgery is not universally applicable to all cases of pressure ulcer surgery.
Antibiotics may be prescribed if there is an infection, but this depends on the individual case and should be determined by the healthcare provider.
Choice D rationale:
Stating that surgery will only address surface issues is not accurate.
Surgical interventions for severe pressure ulcers can involve debridement of necrotic tissue, closure of the wound, and sometimes reconstructive procedures.
The extent of surgery depends on the depth and severity of the ulcer.
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