A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

Patient ate half of his breakfast tray.

Patient has a raised erythematous rash below the knee.

Patient has a capillary refill of less than 2 seconds.

Patient is incontinent of stool.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

The choice "Patient ate half of his breakfast tray" is not the correct answer. While poor appetite or decreased intake can impact a patient's nutritional status, it is not a direct indicator of pressure ulcer risk.

Choice B rationale:

The choice "Patient has a raised erythematous rash below the knee" is not the correct answer. This might indicate a localized skin issue, such as an allergic reaction or dermatitis, but it is not a clear sign of pressure ulcer risk.

Choice C rationale:

The choice "Patient has a capillary refill of less than 2 seconds" is not the correct answer. Capillary refill time assesses peripheral circulation and is useful in evaluating perfusion, but it is not specifically indicative of pressure ulcer risk.

Choice D rationale:

The correct answer is "Patient is incontinent of stool." Choice D is the correct answer. Incontinence, especially fecal incontinence, increases the risk of pressure ulcer development. Prolonged exposure to moisture from urine or stool weakens the skin's integrity, making it more susceptible to breakdown when pressure is applied over bony prominences.

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Correct Answer is C

Explanation

Choice A rationale:

Lillian Wald is known for founding the Henry Street Settlement in New York and for her work in public health nursing and social reform, but she is not specifically associated with keeping records on sanitation techniques and their effects on health.

Choice B rationale:

Clara Barton is renowned for establishing the American Red Cross and her humanitarian efforts during the Civil War. While she contributed significantly to healthcare, her focus was not on keeping records on sanitation techniques and their effects.

Choice C rationale:

Florence Nightingale, the founder of modern nursing, is the nurse who kept records on sanitation techniques and their effects on health. She is known for her work during the Crimean War, where she improved sanitation and hygiene practices in healthcare settings, leading to significant improvements in patient outcomes.

Choice D rationale:

Mary Nutting was an influential figure in nursing education, but she is not primarily recognized for keeping records on sanitation techniques and their effects. Her contributions were more related to curriculum development and nursing education.

A. Partial-thickness skin loss. B. Necrotic subcutaneous tissue. C. Blood-filled blisters. D. Exposed bone.

Correct Answer is B

Explanation

The correct answer is choice B. Necrotic subcutaneous tissue.

Choice A rationale:

Partial-thickness skin loss (Choice A) is characteristic of a stage II pressure ulcer, not a stage III ulcer. A stage II pressure ulcer involves the loss of the epidermis and possibly the dermis, resulting in a shallow open ulcer with a red-pink wound bed.

Choice B rationale:

Necrotic subcutaneous tissue is a manifestation of a stage III pressure ulcer. A stage III ulcer involves full-thickness skin loss where subcutaneous fat may be visible, but exposed bone or muscle is not yet present. Necrotic tissue in the wound bed indicates a more advanced level of tissue damage and the need for appropriate wound care to promote healing.

Choice C rationale:

Blood-filled blisters (Choice C) are not specific to pressure ulcers and are more commonly associated with friction or shear forces. These blisters are not indicative of a stage III pressure ulcer, which involves visible full-thickness tissue loss.

Choice D rationale:

Exposed bone (Choice D) is a characteristic of a stage IV pressure ulcer, not a stage III ulcer. A stage IV ulcer involves extensive tissue loss with exposure of muscle, tendon, or bone. This represents a severe level of tissue damage and requires intensive wound care and management.

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A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nurse kept records on sanitation techniques and the effects on health?

Correct Answer is C

Explanation

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Correct Answer is B

Explanation

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