Three days ago, a client was admitted from home with a reported pressure injury. The provider and wound care nurse were at the bedside.
Which statement best describes the most critical aspect of the client's pressure injury and current treatment?
The client was admitted three days ago.
The pressure injury was at stage 4.
The client reported pain as a 2 on a scale from 0 to 10.
The dressing was reapplied and sealed.
The Correct Answer is B
Choice A rationale
The client was admitted three days ago. This statement is factual, but it does not directly address the current condition of the client’s pressure injury. The time of admission is not as relevant as the progression and treatment of the wound. Therefore, while this choice is accurate, it is not the most critical piece of information in this context.
Choice B rationale
The pressure injury was at stage 4. This is the correct answer. Stage 4 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage or bone.
The presence of slough, eschar, and tunnels, as well as the size of the wound, are consistent with a stage 4 pressure ulcer. The treatment provided, including debridement and negative
pressure wound therapy, is also typical for this stage of pressure injury. Therefore, this choice accurately describes the client’s condition.
Choice C rationale
The client reported pain as a 2 on a scale from 0 to 10. While it’s important to monitor the client’s pain levels, this information alone does not provide a comprehensive understanding of the client’s condition. Pain can be subjective and varies from person to person. A score of 2 indicates minor pain, which is manageable and does not significantly interfere with the client’s daily activities. However, this does not negate the severity of a stage 4 pressure injury.
Choice D rationale
The dressing was reapplied and sealed. This statement describes one aspect of the wound care process. Negative pressure wound therapy involves the application of a vacuum through a special sealed dressing. The dressing is crucial in creating a moist healing environment, reducing edema, and promoting wound healing. However, the reapplication and sealing of the dressing alone do not provide a complete picture of the client’s condition or the severity of the pressure injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Walking briskly is a weight-bearing exercise that is essential for maintaining bone mass, which can help to prevent osteoporosis. Regular weight-bearing exercise, such as a 20-30-minute aerobic exercise, 3 times a week, is recommended for older adults at risk for osteoporosis.
Choice B rationale
Riding a bicycle is a non-weight-bearing exercise. While it can contribute to overall fitness and health, it does not provide the same benefits for bone health as weight-bearing exercises like walking.
Choice C rationale
Performing isometric exercises can help to strengthen muscles, but these exercises do not have the same impact on bone health as weight-bearing exercises.
Choice D rationale
Engaging in high-impact aerobics can be beneficial for bone health, but it may not be suitable for an older adult at risk for osteoporosis due to the increased risk of injury.
Correct Answer is A
Explanation
Choice A rationale
Using a bed exit alarm system is a common intervention to minimize the risk of injury in patients with dementia. These systems alert staff when a patient attempts to leave the bed, allowing for timely intervention to prevent falls.
Choice B rationale
Raising four side rails while the patient is in bed is not a recommended practice. This could be considered a form of restraint and could increase the risk of injury if the patient attempts to climb over the rails.
Choice C rationale
Applying one soft wrist restraint is not a recommended practice for patients with dementia. Restraints should be used as a last resort and only when necessary for the patient’s safety.
Choice D rationale
Dimming the lights in the patient’s room is not a recommended practice to minimize the risk of injury in patients with dementia. Adequate lighting can help prevent falls and other accidents.
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