A nurse is assessing a client's coccyx area and notes visible subcutaneous fat with tunneling. Which of the following pressure injury stages should the nurse document?
Unstageable
Stage 2
Stage 3
Stage 4
The Correct Answer is C
A. Unstageable: An unstageable pressure injury occurs when the full thickness of tissue loss is obscured by slough or eschar. Since subcutaneous fat and tunneling are visible in this case, the injury can be staged and is not unstageable.
B. Stage 2: Stage 2 pressure injuries involve partial-thickness skin loss with exposed dermis. They do not extend into subcutaneous tissue and do not present with tunneling or visible fat, so this stage does not fit the description.
C. Stage 3: A Stage 3 pressure injury involves full-thickness skin loss. At this stage, subcutaneous fat (adipose tissue) is visible within the ulcer. Features like tunneling (a narrow opening or passageway extending from the wound) and undermining (tissue destruction underneath the intact skin at the wound edge) are common. However, the nurse should not be able to see bone, tendon, or muscle; if these deeper structures were visible, the injury would be classified as Stage 4.
D. Stage 4: A Stage 4 pressure injury involves full-thickness skin and tissue loss. The distinguishing factor for Stage 4 is the direct visualization or palpation of fascia, muscle, tendon, ligament, cartilage, or bone within the ulcer. While tunneling can occur in Stage 4, the presence of only subcutaneous fat keeps this specific injury at Stage 3.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Your device is set to allow you to deliver small doses more frequently.": PCA (patient-controlled analgesia) allows the client to self-administer small, controlled doses of pain medication as needed. This statement accurately explains how the device works and emphasizes client control within safe limits.
B. "Using this device allows you to use less medication than other methods.": While PCA can improve pain management, it does not necessarily reduce the total amount of medication used. The primary benefit is timely pain relief and maintaining therapeutic levels, not automatically using less medication.
C. "Your family member can push the PCA button for you if you're sleeping": Only the client should activate the PCA device to prevent overdose. Allowing others to push the button, a practice called “PCA by proxy,” is unsafe and can lead to serious complications.
D. "You will need to keep track of each dose you administer to avoid taking too much.": The PCA device is programmed with safety limits, including lockout intervals, to prevent overdose. The client does not need to manually track doses, as the device automatically controls and records administration.
Correct Answer is A
Explanation
A. Denial: Denial is an expected initial stage of grief in response to terminal illness. Clients may have difficulty accepting the diagnosis and may refuse to believe the reality of their condition as a coping mechanism.
B. Reorganization: Reorganization is a later stage of grief associated with adapting to loss after bereavement. It is not typically part of the immediate response to a terminal diagnosis in the dying process.
C. Numbing: Numbing is more commonly associated with acute grief reactions following sudden loss, rather than the anticipatory grief experienced after a terminal diagnosis.
D. Reinvesting: Reinvesting refers to redirecting emotional energy into new relationships or activities after loss. This stage occurs after bereavement and is not part of the expected stages of grief during the dying process.
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