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","B","C","E"]

Explanation

A. Clients with dementia often experience cognitive decline, which can affect their ability to navigate their surroundings safely. Modifying the environment can include simplifying the layout, reducing clutter, using clear signage, and ensuring adequate lighting to enhance orientation and reduce confusion.

B. Communication difficulties are common in dementia. Using short, simple sentences helps clients better understand instructions and information. It reduces confusion and frustration, promoting effective communication and cooperation during care.

C. Maintaining independence and dignity is crucial for clients with dementia. Allowing them to participate in Activities of Daily Living (ADLs) to the extent possible helps preserve their functional abilities, boosts their self-esteem, and promotes a sense of control over their environment.

E. Providing choices within a structured framework can empower clients with dementia. It allows them to maintain some control over their daily routine and decisions, thereby enhancing their sense of autonomy and reducing agitation or resistance to care.

D. This is not an appropriate intervention. Social interaction, including visits from family members, can have significant emotional and psychological benefits for clients with dementia. It can help reduce feelings of isolation, improve mood, and provide reassurance and familiarity.

A. Handling the skin gently B. Ensure daily bathing C. Clothing that will maintain body warmth D. Using skin moisturizers after bathing E. Fluid intake of no more than about 1000 mL

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

Explanation

A. Older adult skin is typically more fragile and prone to injury and tears due to decreased elasticity and thinning. Handling the skin gently helps prevent trauma, skin tears, and bruising, promoting skin integrity and comfort.

C. Older adults are more susceptible to temperature changes and may have difficulty regulating body temperature. Appropriate clothing that helps maintain warmth without causing overheating is essential. This includes wearing layers that can be easily adjusted and using fabrics that are breathable and comfortable.

D. Older adult skin tends to be drier due to decreased oil production and reduced hydration levels. Applying moisturizers after bathing helps replenish lost moisture, maintain skin hydration, and prevent dryness and cracking. It is important to choose moisturizers that are suitable for older adult skin and free from irritants.

B. Daily bathing may not be necessary or suitable for all older adults. Excessive bathing can strip the skin of natural oils, leading to dryness and irritation. Instead, the nurse should promote bathing frequency based on individual skin needs, such as using mild, moisturizing cleansers and lukewarm water.

E. Adequate hydration is crucial for maintaining skin health and overall well-being in older adults. While fluid needs vary among individuals, restricting fluid intake to such a low level (1000 mL) is generally not

appropriate unless medically indicated. Older adults should be encouraged to maintain adequate hydration to support skin elasticity, circulation, and overall health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for an elderly client who has dementia. Interventions used would include: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","E"]

Explanation

Because of the skin changes in the older adult client, what interventions should the nurse ensure in their care? (SELECT ALL THAT APPLY)

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

Explanation

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