A client with a pressure ulcer reports partial-thickness skin loss involving the epidermis and/or dermis.

Which symptom should the nurse expect to find during the assessment?

"I have a wound that is cold to the touch.".

"The area around the wound is red.".

"I feel tenderness when touching the wound.".

"My wound is deep, down to the muscle.".

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Coldness to the touch is not a characteristic symptom of partial-thickness skin loss involving the epidermis and/or dermis.

This symptom is more indicative of compromised blood flow, such as in arterial insufficiency, and is not specific to pressure ulcers.

Choice B rationale:

Redness around the wound is a characteristic symptom of partial-thickness skin loss (stage 2 pressure ulcer).

This redness is due to localized inflammation and represents damage to the epidermis and/or dermis, but it does not involve muscle or deeper tissues.

Choice C rationale:

Tenderness when touching the wound is an expected symptom in partial-thickness skin loss involving the epidermis and/or dermis (stage 2 pressure ulcer).

The presence of tenderness is indicative of ongoing tissue damage and inflammation in the affected area.

Choice D rationale:

The statement, "My wound is deep, down to the muscle," suggests a full-thickness wound (stage 3 or 4 pressure ulcer) where muscle and deeper tissues are involved.

This statement does not align with the description provided in the question, which specifies partial-thickness skin loss.

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Correct Answer is C

Explanation

Choice A rationale:

"Immobilization has no impact on the risk of pressure ulcer development." This statement is not accurate.

Immobilization significantly increases the risk of pressure ulcer development.

Prolonged pressure on the skin and tissues due to immobility can lead to tissue ischemia and pressure ulcer formation.

Choice B rationale:

"The client's sensory deficits will prevent them from developing pressure ulcers." Sensory deficits, such as those resulting from a spinal cord injury, can actually increase the risk of pressure ulcers.

Patients with sensory deficits may not feel discomfort or pain, making them less likely to reposition themselves and relieve pressure on vulnerable areas.

Choice C rationale:

"Prolonged immobility increases the risk of pressure ulcers due to decreased tissue perfusion." This statement is accurate.

Prolonged immobility reduces tissue perfusion (blood flow) to areas under pressure, increasing the risk of pressure ulcer development.

Choice D rationale:

"The client's spinal cord injury will lead to improved blood flow and oxygenation in the skin." This statement is not accurate.

A spinal cord injury does not lead to improved blood flow and oxygenation in the skin.

In fact, it can contribute to impaired mobility and sensory deficits, which increase the risk of pressure ulcers.

A. "The client's advanced age is the primary factor affecting wound healing.". B. "The client's wound is not adequately protected from friction.". C. "Vascular disease may lead to compromised blood flow and oxygenation in the affected area.". D. "The client's wound healing process is delayed due to a hyperactive immune response.".

Correct Answer is C

Explanation

Choice A rationale:

"The client's advanced age is the primary factor affecting wound healing." While advanced age can affect wound healing, it is not the primary factor in this case.

The client's history of vascular disease is a more significant contributing factor.

Choice B rationale:

"The client's wound is not adequately protected from friction." Friction can impact wound healing, but in this case, vascular disease plays a more substantial role in impaired wound healing.

Choice C rationale:

"Vascular disease may lead to compromised blood flow and oxygenation in the affected area." This statement is correct.

Vascular disease can impair blood flow and oxygenation to tissues, significantly affecting wound healing.

Reduced blood flow deprives tissues of necessary nutrients and oxygen, leading to delayed healing.

Choice D rationale:

"The client's wound healing process is delayed due to a hyperactive immune response." A hyperactive immune response is not typically a primary factor in impaired wound healing associated with vascular disease.

The primary concern in vascular disease is compromised blood flow and tissue perfusion.

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A client with a pressure ulcer reports partial-thickness skin loss involving the epidermis and/or dermis. Which symptom should the nurse expect to find during the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been immobile for an extended period due to a spinal cord injury. The nurse is assessing the client for the risk of developing pressure ulcers. Which statement regarding the client's immobility and pressure ulcer risk is accurate?

Correct Answer is C

Explanation

A nurse is assessing a client who has developed a wound on their lower leg. The client has a history of vascular disease. Which of the following factors is most likely contributing to the client's impaired wound healing process?

Correct Answer is C

Explanation

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A client with a pressure ulcer reports partial-thickness skin loss involving the epidermis and/or dermis. Which symptom should the nurse expect to find during the assessment?

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A client with a pressure ulcer reports partial-thickness skin loss involving the epidermis and/or dermis.

Which symptom should the nurse expect to find during the assessment?