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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Yogurt contains probiotics, which are beneficial bacteria that can help restore and maintain a healthy balance of gut flora. Consuming yogurt with live cultures regularly is a recognized strategy to replenish beneficial bacteria in the gut, especially after a period of diarrhea or antibiotic use that may disrupt the normal gut microbiota.
A. This statement is related to the management of infection and antibiotic therapy, not specifically to reestablishing bowel flora. While stopping antibiotics appropriately is important for overall health and possibly reducing antibiotic-associated diarrhea, it does not directly address the replenishment of bowel flora.
B. Rice is often recommended during episodes of diarrhea to provide bland, easily digestible food. However, it does not actively contribute to reestablishing healthy bowel flora. It helps in managing symptoms but does not address the restoration of beneficial gut bacteria.
D. Hydration is essential during episodes of diarrhea to prevent dehydration. While adequate hydration supports overall health and can aid in recovery, it does not specifically address the restoration of bowel flora.
Correct Answer is B
Explanation
B. This is the best response. It demonstrates empathy, active listening, and a willingness to understand the client's emotions. By inviting the client to express their feelings further, the nurse creates an opportunity for therapeutic communication and can better assess how to support the client emotionally.
A. This response dismisses the client's feelings of anger and sadness and may come across as minimizing their emotions. It does not acknowledge the client's current state of distress or provide validation for their feelings.
C. This response expresses empathy and acknowledges the client's feelings, which is important. However, it may seem somewhat passive and could benefit from further exploration or invitation for the client to elaborate on their feelings.
D. This response is dismissive and judgmental. It may make the client feel invalidated or criticized for expressing their emotions, which can further escalate feelings of anger or distress.
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