A nurse is caring for a patient with a pressure ulcer that presents as non-blanchable erythema with intact skin.
What clinical manifestation is the nurse likely to observe in this patient?
"My wound is warm to the touch.".
"I have an open wound with pus.".
"I feel a sharp pain in the affected area.".
"There's swelling around the wound.".
The Correct Answer is A
Choice A rationale:
The nurse is likely to observe warmth around the pressure ulcer site with intact skin.
This is a characteristic clinical manifestation of a stage 1 pressure ulcer.
In stage 1 pressure ulcers, there is non-blanchable erythema (redness) of the skin due to localized inflammation, and the area may feel warm to the touch.
However, the skin is still intact, and there are no open wounds or pus.
Choice B rationale:
This choice is incorrect because the patient described in the question has intact skin, and there is no mention of an open wound with pus.
Pus is typically associated with wound infection, which is not a feature of stage 1 pressure ulcers.
Choice C rationale:
The patient reporting a sharp pain in the affected area is not consistent with the characteristics of a stage 1 pressure ulcer.
Stage 1 pressure ulcers are typically not associated with pain because they only involve the superficial layers of the skin, and the underlying tissues are not affected.
Choice D rationale:
Swelling around the wound is not a typical clinical manifestation of a stage 1 pressure ulcer.
In stage 1, the skin may appear red and feel warm to the touch due to inflammation, but there is no mention of swelling in the question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.