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A nurse is assessing a bedridden patient and notes a reddened area on the sacrum that does not blanch when pressed. The skin is intact. Based on this finding, which stage of pressure ulcer should the nurse document?

A.

Stage I

B.

Stage II

C.

Stage III

D.

Stage IV

Answer and Explanation

The Correct Answer is A

A. Stage I. A Stage I pressure ulcer is characterized by intact skin with non-blanchable erythema. The affected area may feel warmer or firmer than surrounding skin.

B. Stage II. A Stage II pressure ulcer involves partial-thickness skin loss, often presenting as a shallow open ulcer or intact/blistered skin. Since the skin is still intact in this scenario, it is not Stage II.

C. Stage III. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue but no exposed bone, tendon, or muscle. This does not match the description of an intact but reddened area.

D. Stage IV. A Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. This is much more severe than the described case.


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Related Questions

Correct Answer is D

Explanation

A. “I will keep my cast dry and avoid inserting objects inside to scratch my skin.” Keeping the cast dry prevents it from softening or breaking down, which could lead to improper healing. Avoiding objects inside the cast prevents skin injuries and infections.

B. "If I notice increased swelling, numbness, or severe pain, I will elevate my leg and notify my provider immediately." Increased swelling, numbness, and severe pain can indicate compartment syndrome or impaired circulation. Elevating the leg and seeking medical attention is appropriate.

C. "It's okay to use a blow dryer on a cool setting to help dry my cast if it gets wet." A blow dryer on a cool setting can be used to help dry moisture inside the cast without causing burns or affecting the cast material.

D. “I should expect to feel extreme pain under the cast that doesn't improve with pain medication.” Extreme pain that is unrelieved by medication is abnormal and may indicate complications like compartment syndrome, infection, or pressure ulcers under the cast. The patient needs further education that severe pain should be reported immediately.

Correct Answer is B

Explanation

A. "Handwashing is not necessary since impetigo is not contagious." Impetigo is highly contagious, and proper hand hygiene is essential to prevent its spread to others.

B. “I should apply Mupirocin (Bactroban) to the affected areas as prescribed." Mupirocin (Bactroban) is the standard topical antibiotic treatment for impetigo and should be applied as prescribed to reduce bacterial colonization and promote healing.

C. “I don't need to cover the lesions; they should be left open to the air." Covering the lesions can help prevent the spread of infection by minimizing contact with contaminated surfaces.

D. “I will let my child scratch the lesions to help them dry out faster." Scratching can worsen the infection, spread bacteria to other parts of the body, and lead to secondary infections.

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