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.
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Correct Answer is C
Explanation
Choice A rationale:
"Pressure ulcers occur due to excessive friction on the skin." This statement is not accurate.
While friction can contribute to the development of pressure ulcers, it is not the primary pathophysiological factor.
Pressure ulcers primarily result from tissue ischemia and hypoxia, as well as pressure on the skin and underlying tissues.
Choice B rationale:
"Damage to the skin and underlying tissues in pressure ulcers is primarily caused by a lack of proper hygiene." Hygiene is essential in preventing pressure ulcers, but it is not the primary cause of their development.
Pressure ulcers are mainly caused by sustained pressure on bony prominences, leading to reduced blood flow and oxygenation to the affected area.
Choice C rationale:
"Ischemia and tissue hypoxia play a significant role in the development of pressure ulcers." This statement is correct.
Ischemia (reduced blood flow) and tissue hypoxia (inadequate oxygen supply) are key pathophysiological factors in the development of pressure ulcers.
Prolonged pressure on the skin and tissues leads to compromised blood flow, tissue damage, and ultimately, pressure ulcer formation.
Choice D rationale:
"Pressure ulcers result from a hyperactive immune response in the affected area." This statement is not accurate.
Pressure ulcers are not primarily caused by a hyperactive immune response.
While inflammation may occur in response to tissue damage, it is not the root cause of pressure ulcers.
Correct Answer is C
Explanation
Choice A rationale:
Assessing the patient's pain level and providing appropriate pain management (Choice A) is important for a patient with cellulitis as a complication of a pressure ulcer.
However, the immediate priority should be to treat the underlying infection with antibiotics (Choice C).
Pain management can be addressed after initiating antibiotic therapy.
Choice B rationale:
Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention for preventing pressure ulcers but may not be the most immediate action needed for a patient with cellulitis.
Treating the infection with antibiotics (Choice C) takes precedence.
Choice C rationale:
Administering antibiotics to treat the infection (Choice C) is the most appropriate nursing action for a client with cellulitis as a complication of a pressure ulcer.
Cellulitis is a bacterial infection that requires prompt antibiotic treatment to prevent its spread and complications.
Choice D rationale:
Optimizing the patient's nutrition and hydration (Choice D) is essential for overall health and wound healing, but in the context of cellulitis, treating the infection (Choice C) is the primary concern.
Once the infection is under control, nutritional support can be addressed.
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