The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?

Choice A reason: Pulmonary embolism is not the correct answer, because it is a condition that affects the lungs, not the arm. Pulmonary embolism is a blockage of one or more arteries in the lungs by a blood clot, which can cause shortness of breath, chest pain, and coughing up blood.

Choice B reason: Ischial tuberosity is not the correct answer, because it is a bony projection on the pelvis, not the arm. Ischial tuberosity is the part of the pelvis that supports the weight of the body when sitting, and it can be injured by trauma, overuse, or infection.

Choice C reason: Compartment syndrome is the correct answer, because it is a condition that affects the arm, and it matches the symptoms of the client. Compartment syndrome is a serious complication of a traumatic injury, such as a fracture, that causes increased pressure within a closed space of the body, such as the forearm. This pressure can compromise the blood flow and nerve function of the affected area, causing pain, numbness, weakness, and pale skin.

Choice D reason: Broken arm syndrome is not the correct answer, because it is not a real medical condition. Broken arm syndrome is a madeup term that does not describe any specific diagnosis or treatment.

Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.

Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.

Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.

Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.

Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.