Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer?
There appears to be persistent reddening of the skin.
There is a fluid-filled area under the skin.
There is full-thickness skin loss with a crater.
There is slough on part of the wound area.
The Correct Answer is C
A. This description is more indicative of a stage 1 pressure ulcer, where the skin is intact but shows non- blanchable redness. Stage 1 ulcers do not involve skin loss.
B. This description might indicate a stage 2 pressure ulcer, where there is partial-thickness skin loss involving the epidermis and/or dermis. Stage 2 ulcers are characterized by shallow open ulcers with a red- pink wound bed, without slough.
C. This description accurately defines a stage 3 pressure ulcer. Stage 3 ulcers involve full-thickness skin loss where adipose (fat) tissue may be visible, but deeper structures such as muscle, tendon, and bone are not exposed.
D. Slough refers to yellow, tan, gray, green, or brown necrotic tissue in the wound bed that must be removed to facilitate wound healing. Slough can be present in both stage 3 and stage 4 pressure ulcers, where stage 4 involves full-thickness skin loss with exposure of muscle, bone, or supporting structures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nocturnal enuresis refers to nighttime bedwetting. In clients with paraplegia and neurogenic bladder, nocturnal enuresis can occur due to impaired bladder sensation or control. However, it does not necessarily indicate the immediate need for catheterization unless accompanied by significant bladder distension or discomfort.
B. Suprapubic discomfort or pain suggests bladder distension, which can occur when the bladder fills beyond its capacity. In clients with neurogenic bladder, this discomfort can be an indication that the bladder needs to be emptied to prevent overdistension and potential complications such as urinary retention or bladder rupture. Therefore, suprapubic discomfort may indicate the need for catheterization.
C. Urge incontinence refers to the sudden and uncontrollable urge to urinate, which leads to involuntary leakage of urine. In clients with neurogenic bladder, urge incontinence can occur due to involuntary bladder contractions. While it indicates an inability to control bladder function, it may not always necessitate immediate catheterization unless it persists or is accompanied by other symptoms.
D. Reflex incontinence occurs when the bladder empties without the person's control due to a spinal cord injury or neurological condition. In clients with paraplegia, reflex incontinence is often managed through intermittent catheterization programs. If reflex incontinence episodes are frequent or result in inadequate bladder emptying, it may indicate the need for more frequent catheterization.
Correct Answer is B
Explanation
A. Contact precautions primarily focus on preventing direct transmission of pathogens through physical contact. Therefore, wearing a mask is not typically required unless the client is also suspected or known to have respiratory infections that require airborne precautions. The standard precautions include wearing gloves and a gown when entering the client's room.
B. This is a key principle of contact precautions. The nurse should ensure that equipment (such as blood pressure cuffs, stethoscopes) and supplies (like thermometers) used for the client are dedicated solely to that client and are not shared with other clients. This helps prevent the spread of pathogens to other clients or areas of the healthcare facility.
C. Contact precautions involve limiting the client's movement outside of their room to essential purposes only. Allowing the client to leave the room frequently increases the risk of spreading infectious agents to other areas of the healthcare facility and to other individuals.
D. Potted plants can harbor soil that may contain microorganisms. Contact precautions focus on preventing direct transmission through physical contact, and while soil is not typically a medium for transmission of common healthcare-associated pathogens, removing plants helps maintain cleanliness and reduces potential reservoirs for contamination.
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