You are assessing a client and note a pressure injury on the client’s sacrum. The lesion is a deep depression below the level of skin and into the muscle and there appears to be a spot where the bone is visible. What stage of the pressure injury would you document for this wound?
Stage 4.
Stage 3.
Stage 1.
Stage 2.
The Correct Answer is A
Choice A reason: Stage 4 pressure injury involves full-thickness tissue loss with exposed muscle, bone, or tendon, as described with a deep depression and visible bone. This severe stage requires aggressive interventions like debridement or surgery. Accurate staging ensures proper wound care, preventing infection and promoting healing in advanced pressure injuries.
Choice B reason: Stage 3 involves full-thickness loss to subcutaneous tissue, not muscle or bone, unlike the described injury with visible bone (stage 4). Misstaging as 3 underestimates severity, risking inadequate treatments like simple dressings, delaying surgical intervention or infection control critical for deep pressure injuries with bone exposure.
Choice C reason: Stage 1 is intact skin with erythema, not a deep lesion with bone exposure, which is stage 4. Misstaging as 1 grossly underestimates severity, neglecting urgent needs like debridement or antibiotics, risking infection, sepsis, or further tissue loss in severe pressure injuries requiring advanced wound management.
Choice D reason: Stage 2 involves partial-thickness loss with a shallow wound, not deep muscle or bone exposure, as in stage 4. Misstaging as 2 risks inadequate care, like topical treatments instead of surgical intervention, delaying healing and increasing complications like osteomyelitis in severe pressure injuries with visible bone.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Full thickness skin loss with visible bone indicates a stage 4 pressure injury, not stage 1, which involves intact skin with erythema. Misidentifying this overstates severity, risking inappropriate interventions like surgical debridement instead of preventive measures like repositioning, critical for managing early-stage pressure injuries to prevent progression.
Choice B reason: Stage 1 pressure injury presents as intact skin with non-blanchable localized erythema, often over bony prominences, due to early tissue compression. This finding guides preventive care, like pressure relief and skin protection, to halt progression. Accurate identification ensures timely interventions, reducing risk of deeper tissue damage in at-risk patients.
Choice C reason: Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury, not stage 1, which has intact skin. Assuming this misdiagnoses severity, leading to unnecessary aggressive treatments like wound dressings, while neglecting early interventions like offloading pressure, critical for preventing worsening of stage 1 injuries.
Choice D reason: Partial-thickness skin loss with red tissue indicates a stage 2 pressure injury, not stage 1, which shows intact skin with erythema. Misidentifying this risks inappropriate wound care, delaying preventive strategies like skin moisturizing or repositioning, essential for managing stage 1 injuries and preventing progression to deeper ulcers.
Correct Answer is C
Explanation
Choice A reason: A stethoscope assesses heart sounds, detecting murmurs or irregular beats, but does not measure electrical conduction. It provides auditory data on valve function, not heart rate or rhythm via electrical activity. Electrocardiograms are required for detailed analysis of cardiac electrical patterns, making this choice incorrect.
Choice B reason: A blood pressure cuff measures arterial pressure, reflecting cardiovascular workload, but not electrical conduction. It provides systolic and diastolic values, not heart rhythm or rate data. Electrical activity assessment requires tools like electrocardiograms, rendering this choice irrelevant for the described diagnostic purpose.
Choice C reason: An electrocardiogram (ECG) records the heart’s electrical activity, mapping conduction pathways to assess heart rate and rhythm. It detects arrhythmias, ischemia, or conduction delays by analyzing waveforms like P, QRS, and T, making it the precise tool for evaluating cardiac electrical function, as required by the question.
Choice D reason: Doppler ultrasound evaluates blood flow velocity, used in vascular or fetal assessments, but does not measure cardiac electrical conduction. It lacks the capability to assess heart rate or rhythm through electrical signals, unlike an electrocardiogram, making it an incorrect choice for this diagnostic purpose.
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