A nurse begins her shift and is completing her first turn of the night. While turning, she also assesses her patient's skin. When she turns her patient she finds the following wound on her coccyx. How should she document the following wound? (The base of the wound is muscle, with some subcutaneous tissue)
Stage III Pressure Ulcer
Stage IV Pressure Ulcer
Stage II Pressure Ulcer
Unstageable Ulcer
The Correct Answer is B
Choice A rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.
Choice B rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice C rationale: Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers.
Choice D rationale: Unstageable ulcers have a base covered by slough or eschar, making it difficult to assess the depth of tissue involvement. In this case, the wound's base is described as muscle, indicating a stage IV pressure ulcer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Extension is the movement of a body part away from the midline.
Choice B rationale: Adduction is the movement of a body part toward the midline.
Choice C rationale: Circumduction is the circular movement at the joint.
Choice D rationale: Abduction is the movement of a body part away from the midline.
Correct Answer is D
Explanation
Choice A rationale: The stool test for occult blood is not primarily designed to detect bacteria.
Choice B rationale: Parasites are not typically detected through a stool test for occult blood.
Choice C rationale: Steatorrhea refers to the presence of excess fat in the stool and is not the primary focus of a stool test for occult blood.
Choice D rationale: The purpose of the stool test for occult blood is to check for the presence of blood in the stool, which may not be visible to the naked eye. This can be an indicator of gastrointestinal bleeding.
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