The nurse assesses an open wound that is over the area of the client's greater trochanter. What finding would indicate to the nurse that this is a Stage IV pressure injury?
The ulcer has thick dark eschar over the top
Exposed bone/tendon is visible
There is partial-thickness loss of dermis
The wound extends into the subcutaneous tissue.
The Correct Answer is B
B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.
A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.
C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.
D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. This reflex is an important protective mechanism that prevents objects from entering the throat and causing choking. Assessing the gag reflex before oral care can help ensure the safety of the client, especially if they have difficulty swallowing or are at risk for aspiration.
A. It's important to assess if the client is experiencing any pain, as oral care procedures can sometimes cause discomfort, especially if the client has oral lesions or sensitive gums. However, it is not a priority.
B. Presence of saliva: Saliva is essential for oral health, as it helps to cleanse the mouth and buffer acids produced by bacteria. Assessing the amount of saliva can indicate the overall oral hydration status and potential risk of dry mouth (xerostomia).
D. assessing the condition of the skin around the mouth and on the lips is important. It can reveal issues such as dryness, cracking, lesions, or signs of infection but not directly related to oral care.
Correct Answer is B
Explanation
B Watching exciting or stimulating movies, especially horror movies, before bedtime can hinder sleep onset. Such activities can increase arousal and make it more difficult to relax and fall asleep. This statement suggests a lack of understanding of good sleep hygiene practices. Further teaching is needed to discourage stimulating activities before bedtime.
A. Consistency in sleep schedule helps regulate the body's internal clock (circadian rhythm) and can promote better sleep quality. There is no need for further teaching regarding this statement.
C. This statement reflects good sleep hygiene advice. Getting up and engaging in a quiet, boring activity if unable to fall asleep after about 30 minutes can prevent frustration and anxiety associated with lying awake in bed. This practice helps condition the mind to associate the bed with sleep rather than wakefulness. There is no need for further teaching regarding this statement.
D. This statement also reflects good sleep hygiene practices. Going to bed when feeling naturally tired can enhance the ability to fall asleep quickly. It aligns with the concept of associating the bed with sleepiness and promotes sleep onset. There is no need for further teaching regarding this statement.
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