While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?
Stage II pressure ulcer
Stage IV pressure ulcer
Stage I pressure ulcer
Stage III pressure ulcer
The Correct Answer is A
A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A normal state of awareness is characterized by being aware of oneself and one's surroundings. In this case, a nurse would document the client's condition as being "aware of self and environment" to indicate that the client has a normal state of awareness.
Correct Answer is C
Explanation
Values clarification is the process of assisting another to clarify their own values in order to facilitate decision-making ¹. In this case, the client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counseling practice and work full-time. This demonstrates that the client has prioritized her values and made a decision based on them.
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