A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury?

Stage 2

Stage 1

Stage 3

Stage 4

Answer and Explanation

The Correct Answer is C

Choice A reason: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Since the wound involves subcutaneous tissue, it exceeds the criteria for Stage 2.

Choice B reason: Stage 1 pressure injuries are characterized by non-blanchable erythema of intact skin. While the skin is still intact, it may appear red and not lighten when pressed. Given the description of a wound involving subcutaneous tissue, Stage 1 is not appropriate.

Choice C reason: Stage 3 pressure injuries involve full-thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible, but the depth of tissue damage varies by anatomical location. This aligns with the wound involving subcutaneous tissue.

Choice D reason: Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. While the wound described involves subcutaneous tissue, there is no mention of deeper tissue involvement, excluding Stage 4 classification.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: The nurse would include making decisions about health and lifestyle modifications to manage MS because this helps the patient to make informed choices that can alleviate symptoms and improve their quality of life. Modifying aspects such as diet, exercise, and stress management can play a significant role in managing the disease and preventing relapses.

Choice B reason: Curing the disease is not currently a feasible outcome for multiple sclerosis, as there is no known cure. The focus of the care plan is typically on managing symptoms, slowing the progression of the disease, and improving the patient's quality of life rather than curing the disease.

Choice C reason: Maintaining or improving muscle strength and mobility is crucial for patients with MS, as the disease often affects muscle control and strength. Including this outcome in the care plan helps to reduce the risk of falls, improve the patient's ability to perform daily tasks, and enhance overall physical function.

Choice D reason: Maintaining urinary continence is an important aspect of care for MS patients, as the disease can affect bladder control. Including this outcome helps to ensure the patient's comfort and dignity, prevent urinary tract infections, and improve their quality of life.

Choice E reason: Maintaining independence in performing activities of daily living (ADLs) is essential for patients with MS to ensure they can continue to perform tasks such as bathing, dressing, and eating. This outcome supports the patient's self-esteem and promotes a sense of autonomy.

A. Improve public transportation to the clinic B. Obtain low-cost medications for clinic patients C. Teach clinic staff about cultural health beliefs D. Update equipment and supplies at the clinic

Correct Answer is C

Explanation

Choice A reason: Improving public transportation to the clinic would indeed make it easier for residents to access healthcare services. However, this strategy alone does not directly address the cultural and specific health needs of the Hispanic community.

Choice B reason: Obtaining low-cost medications for clinic patients can alleviate some financial burdens and improve access to necessary treatments. While this is beneficial, it does not tackle the root of health disparities related to cultural differences and health beliefs.

Choice C reason: Teaching clinic staff about cultural health beliefs is crucial for reducing health care disparities and promoting health equity. Understanding the cultural background, health beliefs, and practices of the Hispanic community allows healthcare providers to deliver more culturally competent and patient-centered care, building trust and improving health outcomes.

Choice D reason: Updating equipment and supplies at the clinic can enhance the quality of care provided. However, without addressing the cultural competency of the healthcare staff, this strategy does not directly impact health equity or reduce disparities specific to the Hispanic community.

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A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D","E"]

Explanation

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Correct Answer is C

Explanation

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