The nurse is caring for a 48-year-old female patient with diabetes mellitus (DM), hypertension (HTN), and limited mobility. Upon assessment, she notes that there is a pink, viable wound bed with partial-thickness skin loss. Which stage of wound healing does this describe?
Stage 1
Stage 2
Stage 3
Stage 4
The Correct Answer is B
Choice A rationale
Stage 1 wounds are characterized by non-blanchable redness of intact skin. The presence of partial-thickness skin loss indicates that the wound has progressed beyond stage 1, making this choice incorrect.
Choice B rationale
Stage 2 wounds involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This description matches the nurse’s assessment of the patient’s wound, confirming that it is indeed a stage 2 wound.
Choice C rationale
Stage 3 wounds exhibit full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. The patient’s wound, with partial-thickness skin loss and no mention of exposed subcutaneous structures, does not fit the criteria for stage 3.
Choice D rationale
Stage 4 wounds involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. The patient’s wound does not have these characteristics, ruling out stage 4.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Abdominal pads are generally used for absorption and are not specifically designed to minimize pain during dressing changes.
Choice B rationale
Hydrogel dressings provide moisture to the wound, which can facilitate autolytic debridement and reduce pain during dressing changes. They are cooling and soothing, which can be comfortable for the patient.
Choice C rationale
Wet-to-dry dressings are used for mechanical debridement and can be painful when removed, as they may adhere to the wound bed and pull on new tissue.
Choice D rationale
Dry gauze can adhere to the wound and cause pain upon removal, similar to wet-to-dry dressings, and is not the best choice for minimizing pain.
Correct Answer is B
Explanation
Choice A rationale
A contusion, commonly known as a bruise, is characterized by skin discoloration due to trauma that causes bleeding under the skin. It does not result in a raised scar, which is why it is not the correct term to describe the patient's condition.
Choice B rationale
A keloid is an overgrowth of scar tissue that forms at the site of a healed skin injury. Keloids are more common in people with darker skin tones, such as African Americans, and are characterized by a raised, firm, and sometimes itchy or painful scar that extends beyond the original wound boundaries. This description matches the nurse's assessment of the patient's scar.
Choice C rationale
A laceration refers to a deep cut or tear in the skin or flesh. Because the nurse is assessing a scar, not a fresh wound, laceration is not the appropriate term for documentation.
Choice D rationale
A hematoma is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This term would not be used to describe a raised scar, making it an incorrect choice for documentation.
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