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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

C. A comprehensive approach ensures that all aspects of patient care, safety, and organizational processes are thoroughly reviewed and addressed according to TJC standards. This includes comprehensive assessments of patient needs, care plans, and quality improvement initiatives.

A. This term typically refers to the process of capturing images or videos at intervals over time. In the context of healthcare and TJC requirements, "time-lapsed" is not a standard term used by TJC.

B An emergency situation refers to a sudden and often critical medical situation requiring immediate attention and intervention. While TJC does have standards related to emergency preparedness and response in healthcare facilities, "emergency" is not specifically a type of TJC requirement in the context provided.

D. A focused approach refers to concentrating on specific areas or issues within healthcare organizations to address particular concerns or improvements. However, this is not specific about TJC.

A. “I can understand your concern about learning to inject yourself." B. "Good morning. How did you sleep last night?" C. "Can you describe what the pain in your abdomen feels like?" D. "Do you mean you would like to talk to the nurse practitioner?

Correct Answer is A

Explanation

A. This response acknowledges the patient's concern directly. It demonstrates empathy by indicating that the nurse understands the client's feelings of apprehension or anxiety about self-injection. By expressing understanding, the nurse shows empathy towards the client's emotional state.

B. This question shows concern for the patient's well-being and invites them to share their experiences. While it demonstrates a caring attitude, it focuses more on physical comfort rather than directly addressing the client's emotional concerns. While this question shows a caring attitude, it doesn't specifically convey empathy regarding the client's emotional state or concerns.

C. This question seeks to gather information about the client's symptoms. It shows clinical interest and concern for the client's physical condition, but it doesn't directly convey empathy towards their emotional state or concerns. This question is important for assessing the client's condition but does not demonstrate empathy towards their emotional experience or concerns.

D. This response seeks clarification on the client's request or statement. It shows willingness to understand the client's needs or preferences. While it shows attentiveness and willingness to assist, it doesn't directly convey empathy towards the client's emotional concerns or validate their feelings.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Joint Commission (TJC) requires that a(n)

Correct Answer is C

Explanation

Which response by the nurse best conveys empathy to the client?

Correct Answer is A

Explanation

The nurse is assessing the client for the presence of dysuria. The nurse should ask: "Do you:

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?

The nurse is completing a cardiac assessment on a client. The pulmonic valve would best be assessed by auscultating at the:

As a part of care planning, the nurse considers the client's spiritual needs. What is the Rationale for this concern?

The nurse is instructing nurse externs at an extended care facility. What is the expected range of motion of the hip? (SELECT ALL THAT APPLY)

The nurse takes a client's temperature and gets an unexpected result. Which site would provide the most accurate temperature reading?

A nurse is providing teaching for a client who is placed on a low-sodium diet. Which statement made by the client demonstrates an understanding of dietary teaching? "I will:

A client is being transferred to a subacute care facility. A printed copy of the electronic medical record is sent with the client. Which documents should be included in the client's legal health record? (SELECT ALL THAT APPLY)