A wound care nurse has been consulted on a patient with multiple pressure wounds. The nurse comes across this heal wound. How should she document the following wound?
Unstageable Ulcer
Stage II Pressure Ulcer
Stage IV Pressure Ulcer
Stage III Pressure Ulcer
The Correct Answer is A
Choice A rationale: An unstageable ulcer is covered with slough or eschar, making it difficult to determine the depth of tissue involvement. The presence of eschar prevents accurate staging of the wound.
Choice B rationale: Stage II pressure ulcers involve partial-thickness skin loss, typically presenting as a shallow open ulcer with a red-pink wound bed.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, which is not described in this scenario.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss without exposed bone, tendon, or muscle, but the presence of eschar makes accurate staging challenging.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Overflow incontinence is characterized by a constant leakage of small amounts of urine and a distended, palpable bladder due to incomplete emptying. This is consistent with the client's symptoms.
Choice B rationale: Reflex incontinence is associated with neurologic dysfunction but does not typically involve constant leakage.
Choice C rationale: Stress incontinence is associated with increased intra-abdominal pressure and typically involves leakage with activities like coughing or sneezing.
Choice D rationale: Urge incontinence is characterized by a sudden, strong urge to void and is not typically associated with constant leakage.
Correct Answer is B
Explanation
Choice A rationale: Redness, warmth, swelling, and green drainage are not typically signs of anemia.
Choice B rationale: These symptoms are indicative of infection. Infections can cause localized redness, warmth, swelling, and the drainage of discolored material.
Choice C rationale: While wound healing may involve some inflammation, the described symptoms are more consistent with infection than normal wound healing.
Choice D rationale: Necrosis involves tissue death and is not typically associated with redness, warmth, and swelling.
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