A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

Slough tissue is present.

Adipose tissue is present.

Fascia tissue is present.

Undermining is present.

Answer and Explanation

The Correct Answer is C

A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.

B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.

C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.

D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.

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Correct Answer is B

Explanation

A. "It is okay to take laxatives every day to help you have a bowel movement." Frequent laxative use can lead to dependence and decreased bowel function over time. Instead, non-pharmacologic measures such as fiber intake, hydration, and physical activity should be encouraged first.

B."Do not ignore the urge to have a bowel movement even if you feel it is inconvenient." Ignoring the urge can lead to constipation as stool remains in the colon longer, resulting in increased water absorption and harder stools. Encouraging regular bowel habits helps maintain normal function.

C. "Do not take opiate medications as those can cause constipation." While opiates can cause constipation, this statement is too broad. Some individuals may require opioid therapy for pain management. Instead, the focus should be on preventing and managing opioid-induced constipation rather than avoiding these medications altogether.

D. "Be sure to eat at least 20 grams of fiber and drink at least 1,000mL per day." While increasing fiber intake is important, 20 grams may not be sufficient (the recommended daily fiber intake for older adults is about 25–30 grams). Additionally, 1,000 mL (1 liter) of fluid may be inadequate, as older adults should aim for at least 1,500–2,000 mL per day unless contraindicated.

A. Protective prone B. Left lateral recumbent C. High Fowler's D. Dorsal recumbent

Correct Answer is B

Explanation

A. Protective prone: The prone position (lying on the stomach) does not allow easy enema administration and is not recommended.

B. Left lateral recumbent: The left lateral position allows gravity to assist with enema administration and helps the fluid move efficiently through the colon.

C. High Fowler's: Sitting upright does not promote proper enema flow, making it ineffective.

D. Dorsal recumbent: Lying on the back does not facilitate enema administration effectively.

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A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

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