A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?

Stage 2

Stage 3

Stage 1

Unstageable

Answer and Explanation

The Correct Answer is D

A. Stage 2: A Stage 2 pressure ulcer is characterized by partial-thickness skin loss, which may present as an open wound or blister. The presence of black eschar indicates that the skin loss is deeper than what is described in Stage 2.

B. Stage 3: A Stage 3 pressure ulcer involves full-thickness skin loss, which may extend into the subcutaneous tissue but does not involve bone or muscle. However, the presence of black eschar suggests that the wound cannot be accurately assessed because the base is not visible.

C. Stage 1: A Stage 1 pressure ulcer is identified by intact skin with non-blanchable redness. Since there is a broken skin and black eschar in this case, it cannot be classified as Stage 1.

D. Unstageable: A wound is considered unstageable when there is full-thickness skin loss and the base of the wound is covered with necrotic tissue (eschar) or slough, making it impossible to determine the depth and true stage of the ulcer. In this scenario, the black eschar covering the base of the wound prevents accurate staging, so the wound is classified as unstageable.

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Correct Answer is A

Explanation

A. Provide the client with an electric toothbrush: An electric toothbrush is an appropriate option for a client with impaired upper extremity strength. It requires less physical effort to use compared to a manual toothbrush, making it easier for the client to maintain oral hygiene effectively. The powered brushing action can help ensure more thorough cleaning of the teeth and gums.

B. Give the client an alcohol-based mouth wash: Alcohol-based mouthwashes can be irritating to the oral mucosa, especially in clients who may have dry mouth or other oral health issues. Instead, a non-alcoholic mouthwash or rinse should be considered to promote comfort and effective oral care.

C. Give the client lemon-glycerin mouth swabs: Lemon-glycerin swabs are not recommended for oral care, as they can be irritating and may cause dryness in the mouth. Additionally, lemon can be acidic and potentially harm the enamel of the teeth. It is better to use products designed for sensitive oral care.

D. Provide the client with a spool of dental floss: While dental floss is important for maintaining oral hygiene, using it requires manual dexterity and strength that may be difficult for a client with impaired upper extremity strength. Instead, alternatives such as floss holders or interdental brushes could be suggested, but the initial focus should be on ensuring the client can effectively brush their teeth.

A. Reduced chest width B. Decreased muscle mass C. Thickened vertebral disks D. Increased force of isometric contraction

Correct Answer is B

Explanation

A. Reduced chest width: While aging can lead to changes in the thoracic cavity, such as a decreased ability to expand the chest due to loss of elasticity in lung tissue, reduced chest width is not a primary musculoskeletal change associated with aging. The focus should be on musculoskeletal changes rather than respiratory or thoracic changes.

B. Decreased muscle mass: This is a significant and well-documented age-related change in the musculoskeletal system. Sarcopenia, or the loss of muscle mass and strength with aging, affects mobility and function in older adults. This change should be included in the presentation as it is relevant to the musculoskeletal system and impacts overall health and activity levels.

C. Thickened vertebral disks: With aging, vertebral disks typically degenerate and lose hydration, which can lead to thinning rather than thickening. This degeneration contributes to decreased height and may increase the risk of spinal issues, so thickening is not an accurate representation of age-related changes.

D. Increased force of isometric contraction: Aging generally leads to a decrease in muscle strength and function, including the force of isometric contractions. This decline can affect the ability to perform daily activities and maintain independence, making this statement inaccurate in the context of age-related changes.

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A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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