The nurse has identified the following findings upon assessment of a client's left lower leg wound: copious amounts of drainage and pain relief with elevation. How would the nurse identify this wound in documentation?

Arterial ulcer

Venous ulcer

Unstageable pressure injury

Stage 3 pressure injury

Answer and Explanation

The Correct Answer is B

A. Arterial ulcer: These ulcers result from inadequate blood supply and are characterized by a lack of drainage and intense pain that is exacerbated by elevation. The "copious amounts of drainage" described in the question is the exact opposite of the dry, necrotic appearance typical of arterial insufficiency. They require gravity-dependent positioning for comfort.

B. Venous ulcer: Chronic venous insufficiency leads to high hydrostatic pressure, which forces fluid into the interstitial space, resulting in heavy exudate or "copious drainage." Elevating the leg reduces this pressure and facilitates venous return, which directly relieves the associated aching pain. These findings are classic diagnostic indicators for venous etiology.

C. Unstageable pressure injury: This classification is reserved for wounds where the base is completely covered by slough or eschar, making depth determination impossible. It does not describe the vascular or exudative characteristics of the wound. The description provided focuses on physiological symptoms rather than the visual obstruction of the wound bed.

D. Stage 3 pressure injury: This stage involves full-thickness skin loss where subcutaneous fat may be visible, but bone or tendon is not. While a Stage 3 injury can have drainage, the specific relief of pain with elevation is a systemic vascular finding rather than a characteristic of localized pressure damage. It lacks the defining features of venous stasis.

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Free Nursing Study Resources

Correct Answer is ["10"]

Explanation

Dose prescribed /Dose available×Volume=Amount to administer

10mg5mg×5ml=10ml

Correct answer: 10

A. "When you aren't up and moving your bladder becomes hyperactive, the increased bladder activity can cause urine to overflow." B. "When you lay in bed for extended periods, your bladder, which is made of muscle, can lose its tone, resulting in loss of control." C. "When you lay in a flat position for too long, pressure builds up in the bladder causing spasms and urine leakage." D. "When you don't get enough fluids, your bladder doesn't fill enough causing a loss of muscle tone and control."

Correct Answer is B

Explanation

A. "When you aren't up and moving your bladder becomes hyperactive, the increased bladder activity can cause urine to overflow.": Hyperactivity and overflow incontinence are distinct pathophysiological mechanisms. Immobility does not typically trigger detrusor instability or hyperactive contractions. Overflow is usually caused by an obstruction or an acontractile bladder rather than simple physical inactivity.

B. "When you lay in bed for extended periods, your bladder, which is made of muscle, can lose its tone, resulting in loss of control.": Prolonged immobility leads to deconditioning of the detrusor muscle and the pelvic floor. In the elderly, bed rest rapidly diminishes the ability of the bladder to store urine effectively and maintain urethral pressure. This explains the sudden onset of functional and urge-related incontinence.

C. "When you lay in a flat position for too long, pressure builds up in the bladder causing spasms and urine leakage.": While supine positioning can change intra-abdominal pressure, it does not cause localized bladder spasms in a healthy organ. The issue is more related to global muscle atrophy and loss of neurological coordination. Spasms are usually indicative of infection or irritation.

D. "When you don't get enough fluids, your bladder doesn't fill enough causing a loss of muscle tone and control.": Low fluid intake actually irritates the bladder lining due to concentrated urine, potentially causing urgency, but it does not cause muscle tone loss. Incontinence in an immobile post-operative patient is primarily a result of skeletal and smooth muscle deconditioning.

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The nurse has identified the following findings upon assessment of a client's left lower leg wound: copious amounts of drainage and pain relief with elevation. How would the nurse identify this wound in documentation?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["10"]

Explanation

Correct Answer is B

Explanation

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