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 D
Explanation
Choice A rationale
Prolonged immobility can indeed cause swelling due to fluid accumulation; however, it typically does not lead to sudden worsening or significant swelling at a specific wound site. It is more associated with generalized edema, particularly in dependent areas of the body.
Choice B rationale
While infections can cause swelling, they are also accompanied by other signs such as redness, warmth, pain, and possibly fever. Swelling alone, without these other symptoms, is less indicative of an infection.
Choice C rationale
A deeper injury might cause swelling, but this would have been identified during the initial assessment. Swelling that occurs later in the healing process is less likely to be from a deeper, previously unnoticed injury.
Choice D rationale
Swelling at a wound site is often due to inflammation, where blood vessels dilate and become more permeable, allowing plasma to leak into the tissue. This is a normal part of the healing process as the body brings in necessary cells and substances to promote recovery.
Correct Answer is C
Explanation
Choice A rationale
Sanguineous drainage is indicative of active bleeding and is typically bright red due to the presence of red blood cells. This type of drainage is not yellow-red and is not consistent with the description provided.
Choice B rationale
Serous drainage is clear and watery, and it is the fluid that is seen in blisters. It does not have a yellow-red color, so it does not match the description of the drainage observed.
Choice C rationale
Serosanguineous drainage is a mixture of serous and sanguineous drainage. It is typically light red or pink in color, which corresponds with the moist yellow-red stain described, indicating the presence of both plasma and red blood cells.
Choice D rationale
Purulent drainage is thick and opaque, usually yellow, green, or brown, and is associated with infection. The description of a yellow-red stain does not suggest that the drainage is purulent.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today