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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Apples are a good source of fiber, with about 4.4 grams of fiber in a medium-sized apple with the skin. Apples contain soluble and insoluble fiber, which can aid in digestion and help prevent constipation. This is a suitable choice for a high-fiber snack.
B. Almonds are nutritious and provide fiber, but they are not as high in fiber compared to other options like fruits, vegetables, and whole grains. One ounce of almonds contains about 3.5 grams of fiber. While almonds are beneficial, they are not typically the primary choice for increasing fiber intake to alleviate constipation.
C. Bran cereals are often recommended for their high fiber content. Half a cup of bran cereal can provide around 10 grams of fiber or more, depending on the brand and type. Bran cereals are particularly rich in insoluble fiber, which adds bulk to stool and helps promote regular bowel movements. This is an excellent choice for increasing fiber intake to manage constipation.
D. Sweet potatoes are nutritious and contain dietary fiber, with about 3.8 grams of fiber in half a cup of cooked sweet potatoes. While they contribute to fiber intake, they generally do not provide as much fiber compared to options like whole grains or bran cereals.

A. Oral mucosa B. Eye lids C. Ear lobes D. Tip of the nose

Correct Answer is A

Explanation

A. The oral mucosa, especially the lips and tongue, is a reliable indicator of central cyanosis. Cyanosis is evident as bluish discoloration in these areas due to the presence of deoxygenated hemoglobin.
B. Cyanosis is less reliably visible on the eyelids compared to the lips and oral mucosa. Skin over the eyelids is typically thinner, but detection of cyanosis here can be more challenging due to variations in skin pigmentation and thickness.
C. Similar to the eyelids, cyanosis may be less evident on the ear lobes compared to the lips and oral mucosa. Ear lobes are less vascular and may not consistently show cyanosis unless the condition is severe.
D. The tip of the nose is another area where cyanosis can be detected, although it is less reliable than the lips and oral mucosa. Like the eyelids and ear lobes, the detection of cyanosis here can vary depending on individual skin characteristics.

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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?

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