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The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.
He states that it is painful.
This is a:

A.

pressure injury.

B.

stage 2.

C.

stage 1.

D.

stage 3.

E.

stage 4. .

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.

Choice D rationale:

Stage 3 pressure injuries involve full-thickness skin loss.

Choice E rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.


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Related Questions

Correct Answer is A

Explanation

Choice A rationale:

Dakin solution is used for chemical debridement of a wound.

Choice B rationale:

Primary intention is a method of wound healing, not a result of Dakin solution.

Choice C rationale:

While Dakin solution can aid in wound healing, it does not directly cause healing.

Choice D rationale:

Phagocytosis is a process carried out by certain cells in the body, not a result of Dakin solution.

Correct Answer is B

Explanation

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

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