If a patient has a non-blanchable area of redness on the right malleolus, what stage of pressure injury should be recorded in the patient’s medical record?
Stage 1
Stage 2
Stage 3
Stage 4
The Correct Answer is A
Choice A rationale:
Stage 1 pressure injury:
Non-blanchable erythema of intact skin: This means that when you press on the area, the redness does not disappear. It is persistent and remains even after pressure is relieved, unlike other types of skin redness that may blanch temporarily.
Intact skin: This is a crucial characteristic of Stage 1. The skin is not broken or open, differentiating it from more advanced stages.
Commonly over bony prominences: The malleolus, or ankle bone, is a bony prominence that is susceptible to pressure injuries due to its location and potential for prolonged pressure.
Explanation:
Non-blanchable erythema: The description of the redness as "non-blanchable" is the key indicator of a Stage 1 pressure injury. Blanchable erythema, which disappears when pressure is applied, can be due to other causes like inflammation or skin irritation, but non-blanchable erythema signals a deeper issue with the tissue.
Intact skin: The fact that the skin is intact rules out Stages 2, 3, and 4, which all involve some degree of skin breakdown.
Location on a bony prominence: The malleolus is a common site for pressure injuries because it's a bony area that often bears weight, especially in those with limited mobility or those confined to beds or chairs.
Additional Information:
Pressure injuries, also known as pressure ulcers or bed sores, are areas of damage to the skin and underlying tissue caused by prolonged pressure.
They are a common problem in healthcare settings, particularly among patients with limited mobility. Early identification and intervention are crucial to prevent progression to more severe stages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Burning dried herbs is a form of traditional medicine, not allopathic medicine.
Traditional medicine encompasses a wide range of practices and therapies that have been used for centuries across different cultures.
It often relies on natural substances and processes, such as herbs, acupuncture, and massage, to promote healing and well- being.
While traditional medicine can offer valuable benefits, it's important to note that it's not always based on scientific evidence and its efficacy can vary depending on the specific practice and condition being treated.
Choice B rationale:
Tai chi exercises are a form of complementary and alternative medicine (CAM), not allopathic medicine.
CAM encompasses a diverse group of therapies that are not considered part of mainstream conventional medicine. Tai chi is a mind-body practice that involves gentle, flowing movements and deep breathing.
It has been shown to offer a range of health benefits, including reducing stress, improving balance, and easing pain.
However, it's important to note that tai chi is not a cure-all and should not be used as a substitute for conventional medical care when necessary.
Choice C rationale:
Prescription of antibiotic medication is a hallmark of allopathic medicine.
Allopathic medicine, also known as conventional or Western medicine, is based on the scientific understanding of the body and disease.
It focuses on diagnosing and treating specific diseases or conditions using medications, surgery, or other interventions that have been proven effective through rigorous scientific research.
Antibiotics are a type of medication that specifically targets and kills bacteria.
They are essential for treating bacterial infections, which can cause a wide range of illnesses, from minor skin infections to life- threatening pneumonia.
Choice D rationale:
Manipulation of the spine, also known as chiropractic care, is a form of CAM, not allopathic medicine. Chiropractic care focuses on the musculoskeletal system, particularly the spine.
Chiropractors use manual adjustments to the spine to relieve pain, improve range of motion, and restore function.
While some studies have shown that chiropractic care can be effective for certain conditions, such as lower back pain, it's important to note that it's not a cure-all and should not be used as a substitute for conventional medical care when necessary.
Correct Answer is C
Explanation
Rationale for Choice A:
Mixing insulin detemir and insulin aspart in the same syringe is not recommended due to their differing physicochemical properties and potential for altered absorption and action profiles.
It's crucial to follow manufacturer guidelines, as mixing may lead to suboptimal glycemic control or unpredictable insulin activity.
Rationale for Choice B:
The order of mixing insulin detemir and insulin aspart, even if done incorrectly in the same syringe, would not significantly impact the overall contraindication of mixing them.
The primary concern remains the potential for altered pharmacodynamics and pharmacokinetics when these insulins are combined.
Rationale for Choice C:
Drawing up insulin aspart and insulin detemir in separate syringes is the correct procedure.
This approach ensures that each insulin maintains its intended action profile and absorption characteristics, leading to more predictable glycemic control.
It also aligns with best practices and guidelines for insulin administration.
Rationale for Choice D:
While drawing up insulin detemir first in a separate syringe is technically correct, it offers no specific advantage over drawing up insulin aspart first in a separate syringe.
The key principle is to avoid mixing the two insulins in the same syringe.
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