The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage to the subcutaneous tissues has occurred. How would the nurse document this wound?
stage 4 pressure injury
stage 3 pressure injury
stage 2 pressure injury
stage 1 pressure injury
The Correct Answer is B
A. stage 4 pressure injury: A stage 4 pressure injury involves full-thickness skin and tissue loss with exposed bone, tendon, or muscle, which is beyond subcutaneous tissue damage. These wounds may also include undermining or tunneling and carry a high risk for infection.
B. stage 3 pressure injury: Stage 3 pressure injuries involve full-thickness skin loss that extends into the subcutaneous tissue but does not expose bone, tendon, or muscle, aligning with the description of the wound. This stage may also include slough, undermining, or tunneling.
C. stage 2 pressure injury: A stage 2 injury involves partial-thickness skin loss with exposure of the dermis, typically presenting as a shallow open ulcer, not reaching subcutaneous layers. It may also appear as an intact or ruptured serum-filled blister.
D. stage 1 pressure injury: Stage 1 is characterized by non-blanchable erythema of intact skin without any tissue loss or damage to deeper layers.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. poor tissue repair: Tissue repair mainly occurs during deep (slow-wave) sleep rather than REM sleep, so deprivation of REM sleep is less likely to directly impair this process.
B. difficulty with memory: REM sleep plays a critical role in cognitive functions such as memory consolidation and learning. Continuous deprivation of REM sleep can significantly impair memory retention and cognitive performance.
C. increased susceptibility to disease: While overall sleep deprivation can weaken the immune system, REM sleep deprivation specifically has a more pronounced effect on brain function than direct immune defense.
D. gastrointestinal upset: Gastrointestinal symptoms are not typically linked to REM sleep deprivation but may be associated with general stress or other sleep disorders.
Correct Answer is D
Explanation
A. "I heard you immediately when you came in my room": In REM sleep, the brain is highly active, but the body is in a state of paralysis. A person in REM sleep is less likely to respond quickly to external stimuli, such as hearing someone enter the room.
B. "I feel really cold": Feeling cold is not typically associated with REM sleep. It could be due to other factors like body temperature regulation or environmental conditions but is not a key feature of REM sleep.
C. "It feels like I just went to sleep": This suggests the person was likely in a deeper stage of non-REM sleep. REM sleep typically has an active brain with vivid dreams, making it unlikely for the client to feel like they just fell asleep.
D. "I was having a great dream and I remember all of it": Vivid dreams and memory recall are characteristic of REM sleep. This stage is when the brain is most active in terms of dreaming, making it common for individuals to remember their dreams if they are awakened during this phase.
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