A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?

Stage 2

Stage 3

Stage 1

Unstageable

Answer and Explanation

The Correct Answer is D

A. Stage 2: A Stage 2 pressure ulcer is characterized by partial-thickness skin loss, which may present as an open wound or blister. The presence of black eschar indicates that the skin loss is deeper than what is described in Stage 2.

B. Stage 3: A Stage 3 pressure ulcer involves full-thickness skin loss, which may extend into the subcutaneous tissue but does not involve bone or muscle. However, the presence of black eschar suggests that the wound cannot be accurately assessed because the base is not visible.

C. Stage 1: A Stage 1 pressure ulcer is identified by intact skin with non-blanchable redness. Since there is a broken skin and black eschar in this case, it cannot be classified as Stage 1.

D. Unstageable: A wound is considered unstageable when there is full-thickness skin loss and the base of the wound is covered with necrotic tissue (eschar) or slough, making it impossible to determine the depth and true stage of the ulcer. In this scenario, the black eschar covering the base of the wound prevents accurate staging, so the wound is classified as unstageable.

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Correct Answer is A

Explanation

A. Place a seat alarm in the client's chair: This action is the most appropriate first step. A seat alarm can alert the nurse if the client attempts to stand or leave the chair, allowing for timely intervention while promoting the client's dignity and autonomy. This approach aims to enhance safety without the use of restraints or medications.

B. Administer lorazepam to the client: While lorazepam may help manage agitation, it should not be the first action taken. Pharmacological interventions should be considered after non-pharmacological strategies have been explored. Additionally, administering medication requires careful assessment of the client’s current state and potential side effects.

C. Apply a vest restraint on the client: Restraints should be used only as a last resort and after all other options have been considered. Applying a vest restraint can lead to increased agitation and feelings of helplessness, which may exacerbate the client’s condition. The nurse should prioritize less restrictive interventions.

D. Place the client in bed with the two side rails raised: This action can pose safety risks, as raising side rails may create a false sense of security and could lead to falls if the client attempts to get out of bed. Additionally, confining the client to bed can lead to increased confusion and agitation. It is important to provide a safe environment that encourages mobility while minimizing the risk of falls.

A. Droplet B. Contact C. Protective D. Airborne E. Full semen

Correct Answer is A

Explanation

A. Droplet: Pertussis, also known as whooping cough, is transmitted through respiratory droplets when an infected person coughs or sneezes. Therefore, droplet precautions are necessary to prevent the spread of the infection to others. This includes wearing a surgical mask when within 3 feet of the client and ensuring the client wears a mask when outside of their room.

B. Contact: Contact precautions are used for infections that can be spread through direct or indirect contact with the patient or contaminated surfaces. While there may be some overlap, contact precautions are not the primary focus for pertussis transmission.

C. Protective: Protective precautions (also known as reverse isolation) are utilized to protect immunocompromised patients from infections. This is not applicable for a patient with pertussis, as the focus is on preventing the spread of the infection rather than protecting the patient from pathogens.

D. Airborne: Airborne precautions are used for infections that are transmitted via airborne droplet nuclei, such as tuberculosis or measles. Pertussis does not fall under this category, as it is primarily transmitted through larger respiratory droplets.

E. Full semen: This option is not a recognized type of precaution. The correct term should focus on standard and transmission-based precautions relevant to infectious diseases.

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A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?

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