Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)
irregular wound borders
distinct wound borders to plantar aspect of foot
Patient reports 9 (0-10) scale to area
minimal serous drainage
+3 edema to the mid-calf
Correct Answer : A,E
A. Venous ulcers often have irregular wound borders. This is due to the underlying venous hypertension and tissue breakdown, which can lead to irregular shapes of the ulcer.
E. Significant edema, particularly in the lower leg and ankle area (often graded as +2 or +3), is commonly associated with venous ulcers. Venous insufficiency leads to fluid accumulation in the tissues, resulting in edema.
B. This is less likely to be associated with a venous ulcer. Venous ulcers typically occur on the lower leg, particularly around the medial or lateral malleolus, rather than on the plantar aspect of the foot.
C. Severe pain, especially on a scale of 9 out of 10, is less typical of venous ulcers. Venous ulcers are usually associated with mild to moderate discomfort or pain, often described as aching or heaviness rather than severe pain.
D. Venous ulcers typically exhibit moderate to heavy serous drainage. This is due to the chronic inflammation and venous congestion that characterize venous insufficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Gender can influence health beliefs and practices due to societal norms, roles, and expectations associated with masculinity and femininity. For example, certain health issues may be more prevalent or
stigmatized based on gender. Understanding a client's gender-related health beliefs can help nurses tailor care that respects and addresses these factors.
B. Socioeconomic status (SES) impacts access to healthcare resources, health literacy, and health behaviors. Clients with higher SES may have greater access to healthcare facilities, medications, and preventive services. However, this is an external variable.
C. Family health practices often shape an individual's beliefs about health and illness. Clients may adopt health behaviors based on familial traditions, cultural practices, or experiences with illness within the family. However, this is an external variable.
D. Education level influences health literacy, understanding of medical information, and decision-making regarding healthcare. Higher education levels are often associated with better health outcomes due to increased knowledge of health-related issues, ability to navigate healthcare systems, and adherence to medical advice. However, this is an external variable.
Correct Answer is D
Explanation
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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