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
Correct Answer is C
Explanation
Choice A rationale:
Indurated describes tissue that is hardened and thickened, typically due to inflammation or fibrosis. While a decubitus ulcer with thick necrotic tissue may feel firm to the touch, induration does not accurately capture the extent of tissue damage and depth of the wound.
Indurated tissue often feels leathery or stiff, while necrotic tissue can be more varied in texture, ranging from dry and crusty to soft and sloughy.
Additionally, induration can occur in wounds that are not full-thickness ulcers, such as pressure injuries that have not yet progressed to the point of tissue loss.
Choice B rationale:
Fluctuant describes a fluid-filled cavity beneath the skin. While a decubitus ulcer with thick necrotic tissue may have some underlying fluid, it would not typically be described as fluctuant.
Fluctuance is more characteristic of abscesses or other fluid collections that have a distinct, palpable pocket of fluid.
The presence of thick necrotic tissue in a decubitus ulcer can obscure the presence of any underlying fluid, making it difficult to assess for fluctuance.
Choice D rationale:
Macerated describes skin that is softened and broken down due to prolonged exposure to moisture. While maceration can occur in the surrounding skin of a decubitus ulcer, it does not accurately describe the ulcer itself.
Maceration is typically seen in areas where skin folds rub together, such as the groin or armpits, and is often associated with incontinence or excessive sweating.
The presence of thick necrotic tissue in a decubitus ulcer indicates a more advanced stage of tissue damage that is not simply due to moisture exposure.
Choice C rationale:
Unstageable is the most accurate term to describe a decubitus ulcer with thick necrotic tissue because it indicates that the extent of tissue damage cannot be fully assessed.
Thick necrotic tissue obscures the base of the wound and the surrounding tissue, making it impossible to determine the depth of the ulcer or the extent of undermining.
This lack of visibility prevents accurate staging of the ulcer using the traditional pressure ulcer staging system, which categorizes ulcers based on their depth and extent of tissue involvement.
Therefore, unstageable is the most appropriate term to describe a decubitus ulcer with thick necrotic tissue.
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.