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. Range-of-motion (ROM) exercises are essential in preventing contractures. These exercises aim to maintain or improve joint mobility by moving each joint through its full range of movement. They help stretch tight muscles and maintain flexibility, thereby preventing the progression of contractures.
A. While muscle strengthening exercises are beneficial for overall muscle health, in the context of contractures, the primary issue is the shortened and tight muscles. Strengthening exercises alone may not effectively address the contractures and could potentially exacerbate them.
B. Frequent repositioning is crucial to prevent and potentially reverse contractures. By changing the client's position regularly, pressure and stress on specific muscle groups are relieved, which can help prevent further tightening and promote flexibility. This intervention helps maintain joint mobility and prevents contractures from worsening.
D. Weight-bearing activities can be beneficial for joint health and bone density but may not directly address contractures. Contractures involve structural changes in the muscle-tendon unit rather than joint stiffness alone.
Correct Answer is A
Explanation
A. One of the primary reasons for administering IV fluids is to correct imbalances in fluid volume or electrolyte concentrations. Examples include correcting dehydration, restoring electrolyte levels (such as sodium, potassium), and addressing fluid losses due to vomiting, diarrhea, or excessive sweating.
B. IV fluids are typically used to increase intravascular volume rather than decrease it. In conditions such as hypovolemia (low blood volume), IV fluids are administered to restore blood volume and improve circulation.
C. Third spacing refers to the abnormal accumulation of fluid in interstitial spaces, which can occur in conditions like sepsis, burns, or trauma. IV fluids are not typically administered to increase third spacing; rather, treatment aims to redistribute fluids and improve fluid balance.
D. Enteral fluids are fluids administered directly into the gastrointestinal tract (via oral or tube feeding). IV fluids are administered directly into the bloodstream and are used when enteral administration is not feasible or sufficient.
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