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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Spiritual care is integral to holistic care. Addressing spiritual needs can provide comfort, meaning, and a sense of peace to clients, which can contribute to a reduction in suffering, both physical and emotional. Spiritual distress can exacerbate physical symptoms and affect overall well-being, so addressing these needs can lead to better outcomes.

B. While nurses play a significant role in providing holistic care, including spiritual care, they are not the sole providers. Spiritual care can be provided by chaplains, spiritual counselors, and other healthcare professionals trained in addressing spiritual needs. However, nurses often have frequent and intimate contact with patients, making them well-positioned to assess and address spiritual concerns and to collaborate with other members of the healthcare team to meet these needs.

C. While addressing spiritual needs can contribute to overall well-being and healing, physical healing does not solely depend on meeting spiritual needs. Physical healing involves medical interventions, treatments, and physiological processes. However, addressing spiritual needs can positively impact a client's emotional and psychological state, which can support the overall healing process.

D. Understanding and respecting the client's own beliefs, values, and preferences regarding spirituality is crucial. Each individual may have unique spiritual beliefs and practices that influence their health beliefs and behaviors. The nurse should approach spiritual care with cultural sensitivity and respect for diversity, ensuring that the care provided aligns with the client's beliefs and preferences.

A. Offer the client a few pieces of chocolate before bedtime. B. Monitor the temperature in the client's room. C. Make certain bed linens are clean and dry. D. Assess the client for any issues with discomfort. E. Move the client closer to the nursing station.

Correct Answer is ["B","C","D"]

Explanation

B. Temperature can significantly affect sleep quality. Ensuring the room is kept at a comfortable temperature (not too hot or cold) can promote better sleep. This intervention is appropriate.

C. Clean and dry bed linens contribute to comfort, which is essential for promoting sleep. This intervention is appropriate.

D. Discomfort can be a major barrier to sleep. Addressing any discomfort, such as pain, anxiety, or positioning issues, can help improve the client's ability to fall and stay asleep. This intervention is appropriate.

A. Offering chocolate, which contains caffeine, close to bedtime is not recommended as caffeine can interfere with sleep. Therefore, this option is not appropriate.

E. Moving the client closer to the nursing station may increase noise and disrupt sleep, especially if there are frequent activities or conversations near the nursing station. Therefore, this option is not typically recommended unless the client requires closer monitoring due to medical reasons.

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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?

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