During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

An area of erythema that is painful to touch.

Shallow open ulcer with a red pink wound bed.

A deep pocket of infection and necrotic tissues.

Visible subcutaneous tissue with sloughing.

Answer and Explanation

The Correct Answer is B

A. A stage 2 pressure injury is more than just erythema; it involves partial-thickness skin loss.
B. A stage 2 pressure injury presents as a shallow open ulcer with a red or pink wound bed, indicating partial-thickness loss of dermis.
C. A deep pocket of infection and necrotic tissue describes a stage 3 or 4 pressure injury, not stage 2.
D. Visible subcutaneous tissue and sloughing are characteristics of stage 3 or 4 pressure injuries, not stage 2.

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Correct Answer is B

Explanation

A. Pulse volume and bruit are different assessments; pulse volume is not graded in the context of auscultation findings.
B. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, often due to stenosis or narrowing. Documenting a "left carotid artery bruit present" accurately reflects the findings.
C. The presence of a bruit does not necessarily mean the pulse is strong or that there is occlusion.
D. A bruit indicates turbulent flow, not necessarily complete occlusion.

A. Maintain a cheerful and calm appearance while spending time with the client. B. Listen for changes in what the client hopes for and try to help meet the goals. C. Avoid the client having to make any decisions to help save the client's energy. D. Offer meals prepared with the client's favorite foods at frequent, regular intervals.

Correct Answer is B

Explanation

A. A cheerful and calm appearance may not always align with the client's emotional needs and could feel insincere.
B. As the client nears the end of life, their hopes may shift, and it is crucial for the spouse to listen and help fulfill these evolving goals to provide comfort and maintain dignity.
C. Encouraging the client to make decisions as they are able can empower them, rather than avoiding decision-making.
D. Offering favorite foods is thoughtful but does not directly address the emotional and psychological aspects of hopelessness.

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During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

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