The nurse assesses an open wound that is over the area of the client's greater trochanter. What finding would indicate to the nurse that this is a Stage IV pressure injury?
The ulcer has thick dark eschar over the top
Exposed bone/tendon is visible
There is partial-thickness loss of dermis
The wound extends into the subcutaneous tissue.
The Correct Answer is B
B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.
A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.
C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.
D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is essential to prevent falls, which are a common and serious risk for the elderly. A clutter-free environment allows for safe and easy mobility.
B. Raising the bed, can actually increase the risk of falls if the bed is too high for safe exit.
C. Bright lighting can cause glare and visual discomfort for elderly individuals, especially those with age- related eye conditions such as cataracts or macular degeneration. However, adequate lighting is crucial for safety. The key is to provide sufficient lighting that is evenly distributed and free of glare or harsh shadows, which can help prevent falls.
D. While keeping linens away from the nursing uniform is good practice for infection control, it does not directly relate to the immediate physical safety of the client in the same way that a clear environment does.
Correct Answer is D
Explanation
D. It acknowledges the client's emotions by expressing empathy ("I am sad for you") and offering support ("I'll stay with you for a while if you need to talk"). This approach validates the client's grief, acknowledges the significance of their loss, and offers the opportunity for the client to express their feelings if they choose to do so.
A. This can inadvertently minimize the client's grief by suggesting that the nurse's losses are comparable or that the nurse understands the client's emotions completely.
B. It does not acknowledge or validate the client's current emotions and may overlook the complex feelings associated with losing a parent.
C. This response, although intended to provide encouragement, may not be therapeutic in the context of immediate grief. It suggests a future positive outcome from the loss without acknowledging the client's current emotional pain.
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