The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

Stage 1 pressure ulcer

Stage 4 pressure ulcer

Stage 2 pressure ulcer

Stage 3 pressure ulcer

Answer and Explanation

The Correct Answer is D

A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.

B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.

C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.

D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.

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Correct Answer is C

Explanation

A. A guaiac test does not check for parasites. Tests for parasites typically involve microscopic examination of the stool or other specialized tests.

B. Steatorrhea refers to fat in the stool, and this is detected through tests that measure fat content in the stool, not a guaiac test.

C. A guaiac test is specifically used to detect occult (hidden) blood in the stool, which can indicate gastrointestinal bleeding, polyps, or colorectal cancer.

D. Bacteria in the stool is detected through stool cultures, not a guaiac test.

A. Assist the client to the bathroom every 2 hr. B. Encourage the client to hold her urine when feeling the urge to urinate. C. Restrict oral fluid intake during waking hours. D. Provide adult diapers until bladder retraining is successful.

Correct Answer is B

Explanation

A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.

B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.

C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.

D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.

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The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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