The nurse observes that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the stage for this pressure injury?

Stage IV

Stage II

Stage III

Unstageable

Answer and Explanation

The Correct Answer is D

D. Unstageable pressure injuries are covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it difficult to determine the depth of tissue damage. If the wound over the sacrum is covered with dark, hard tissue that makes it impossible to visualize the depth of the wound, it could be considered unstageable

A. The description of tissue over the sacrum being dark, hard, and adherent to the wound edge suggests extensive tissue damage and possibly involvement of deeper structures like muscle or bone.

B. Stage II pressure injuries involve partial-thickness loss of skin with exposed dermis. These wounds are shallow and typically present as abrasions, blisters, or shallow ulcers.

C. Stage III pressure injuries involve full-thickness skin loss with visible adipose (fat) tissue in the ulcer. These wounds may also have undermining or tunneling.

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Correct Answer is C

Explanation

C. Yogurt contains probiotics, which are beneficial bacteria that can help restore and maintain a healthy balance of gut flora. Consuming yogurt with live cultures regularly is a recognized strategy to replenish beneficial bacteria in the gut, especially after a period of diarrhea or antibiotic use that may disrupt the normal gut microbiota.

A. This statement is related to the management of infection and antibiotic therapy, not specifically to reestablishing bowel flora. While stopping antibiotics appropriately is important for overall health and possibly reducing antibiotic-associated diarrhea, it does not directly address the replenishment of bowel flora.

B. Rice is often recommended during episodes of diarrhea to provide bland, easily digestible food. However, it does not actively contribute to reestablishing healthy bowel flora. It helps in managing symptoms but does not address the restoration of beneficial gut bacteria.

D. Hydration is essential during episodes of diarrhea to prevent dehydration. While adequate hydration supports overall health and can aid in recovery, it does not specifically address the restoration of bowel flora.

A. Meeting the client's spiritual needs can help decrease suffering. B. Nurses are the only health professionals who provide this type of holistic care. C. Until spiritual needs are met, physical needs cannot be healed. D. It is important that the nurse's idea of spirituality matches the client's ideas.

Correct Answer is A

Explanation

A. Spiritual care is integral to holistic care. Addressing spiritual needs can provide comfort, meaning, and a sense of peace to clients, which can contribute to a reduction in suffering, both physical and emotional. Spiritual distress can exacerbate physical symptoms and affect overall well-being, so addressing these needs can lead to better outcomes.

B. While nurses play a significant role in providing holistic care, including spiritual care, they are not the sole providers. Spiritual care can be provided by chaplains, spiritual counselors, and other healthcare professionals trained in addressing spiritual needs. However, nurses often have frequent and intimate contact with patients, making them well-positioned to assess and address spiritual concerns and to collaborate with other members of the healthcare team to meet these needs.

C. While addressing spiritual needs can contribute to overall well-being and healing, physical healing does not solely depend on meeting spiritual needs. Physical healing involves medical interventions, treatments, and physiological processes. However, addressing spiritual needs can positively impact a client's emotional and psychological state, which can support the overall healing process.

D. Understanding and respecting the client's own beliefs, values, and preferences regarding spirituality is crucial. Each individual may have unique spiritual beliefs and practices that influence their health beliefs and behaviors. The nurse should approach spiritual care with cultural sensitivity and respect for diversity, ensuring that the care provided aligns with the client's beliefs and preferences.

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The nurse observes that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the stage for this pressure injury?

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