The nurse observes that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the stage for this pressure injury?
Stage IV
Stage II
Stage III
Unstageable
The Correct Answer is D
D. Unstageable pressure injuries are covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it difficult to determine the depth of tissue damage. If the wound over the sacrum is covered with dark, hard tissue that makes it impossible to visualize the depth of the wound, it could be considered unstageable
A. The description of tissue over the sacrum being dark, hard, and adherent to the wound edge suggests extensive tissue damage and possibly involvement of deeper structures like muscle or bone.
B. Stage II pressure injuries involve partial-thickness loss of skin with exposed dermis. These wounds are shallow and typically present as abrasions, blisters, or shallow ulcers.
C. Stage III pressure injuries involve full-thickness skin loss with visible adipose (fat) tissue in the ulcer. These wounds may also have undermining or tunneling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
B. According to Medicare and The Joint Commission guidelines, the use of patient restraints requires a physician's order. The order should specify the reason for the restraint, the type of restraint, and the duration or conditions for its use.
C. Before using restraints, healthcare providers must exhaust all alternative, less restrictive measures to manage the patient's behavior or condition. This could include environmental modifications, reassurance techniques, or pharmacological interventions.
E. Restraints should be removed or released every 2 hours for reevaluation and to provide opportunities for range of motion exercises, toileting, hydration, and skin care. Restraints should not be used continuously without periodic assessment and reevaluation.
A. Punitive measures are not appropriate or effective in the use of patient restraints. Restraints should only be used for medical reasons to ensure patient safety, not as a form of punishment.
D. Inadequate staffing is not a criterion specified for using patient restraints. Restraints should not be used as a substitute for sufficient staffing levels to monitor and manage patient care.
Correct Answer is D
Explanation
D. This is the most appropriate goal for a client experiencing diarrhea. Diarrhea is characterized by loose or watery stools, and the goal of treatment is to restore normal stool consistency. This goal focuses on improving the symptoms and resolving the underlying cause of diarrhea, whether it's due to infection, dietary factors, or other reasons.
A. "Defecating regularly" does not necessarily imply improvement in diarrhea symptoms or resolution of the underlying cause. It is vague and does not provide a clear target related to diarrhea management.
B. Increasing ingestion of fruits may be beneficial for some individuals as fruits contain fiber and fluids that can help regulate bowel movements and maintain hydration. However, certain fruits high in fiber (e.g., apples, pears) may exacerbate diarrhea in some cases. This goal should be tailored based on the individual's tolerance and specific dietary needs.
C. This goal is not appropriate for managing diarrhea. Diarrhea leads to fluid loss and dehydration, so limiting fluid intake can worsen dehydration and electrolyte imbalances. Adequate fluid intake is crucial to replace lost fluids and maintain hydration during episodes of diarrhea.
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