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 B
Explanation
B. Drug absorption refers to the process by which a drug moves from its site of administration into the bloodstream. Once absorbed into the bloodstream (systemic circulation), drugs can distribute to various tissues and exert their therapeutic effects.
A. Different routes of drug administration affect the rate and extent of absorption. Subcutaneous injections are generally absorbed more quickly than intramuscular injections due to differences in blood flow and tissue characteristics.
C. The effect of meals on drug absorption varies depending on the specific medication. Some drugs are absorbed faster on an empty stomach, while others may be absorbed better with food.
D. Mucous membranes, contrary to the statement, are relatively permeable to drugs, allowing for rapid absorption when medications are administered via buccal, sublingual, rectal, or vaginal routes.
Correct Answer is ["A","B","C","E"]
Explanation
A. External rotation of the hip involves rotating the thigh outward away from the midline of the body. This movement occurs in the hip joint. External rotation is a component of hip range of motion.
B. Extension of the hip involves moving the thigh backward, straightening the leg from a flexed position. This movement also occurs in the hip joint. Extension is part of the hip's range of motion.
C. Adduction of the hip involves moving the thigh toward or across the midline of the body. It brings the leg closer to the midline. Adduction is another movement that is part of the hip's range of motion.
E. Flexion of the hip involves bringing the thigh toward the abdomen or bending the leg. It is a movement where the angle between the thigh and the abdomen decreases. Flexion is a fundamental movement of the hip joint.
D. Supination is a movement primarily associated with the forearm and hand, involving turning the palm upward or facing forward. It is not a movement of the hip joint. Supination is not correct in the context of hip range of motion.
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