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 ["B","D","E"]

Explanation

A. Lactose intolerance does not directly increase the risk of aspiration. It is a condition where the body cannot easily digest lactose, a type of sugar found in dairy products, leading to gastrointestinal symptoms such as bloating, diarrhea, and gas. Aspiration risk is not typically associated with lactose intolerance.
B. Clients who have had a stroke often experience dysphagia (difficulty swallowing) due to impaired coordination of the muscles involved in swallowing. This dysphagia can lead to food or liquids entering the airway instead of the esophagus, increasing the risk of aspiration.
C. Prolonged diarrhea does not directly increase the risk of aspiration during eating. Diarrhea is a gastrointestinal symptom that typically affects the lower digestive tract and is not directly related to swallowing or aspiration risk.
D. After surgery, especially under general anesthesia, clients may have impaired protective airway reflexes and reduced consciousness level, increasing the risk of aspiration. The recovery phase postoperatively is critical, as clients may not have regained full control of their swallowing reflexes.
E. Radiation therapy in the head and neck region can cause tissue damage, including to the muscles and nerves involved in swallowing. This damage can result in dysphagia and increase the risk of aspiration during eating.

A. Reposition the client at least every 2 hr. B. Keep the head of the bed elevated. C. Keep the client's skin moist. D. Massage the client's bony prominences.

Correct Answer is A

Explanation

A. Repositioning the client regularly is a critical measure to prevent pressure ulcers. This helps relieve pressure on vulnerable areas of the body and improves circulation. Turning the client every 2 hours is a common guideline to prevent prolonged pressure on any one area.
B. Keeping the head of the bed elevated continuously is not recommended as it can increase shear and friction, leading to skin breakdown.
C. Keeping the client's skin moisturized is important for maintaining skin integrity, but excessive moisture can increase the risk of skin breakdown, especially in areas susceptible to pressure ulcers. The nurse should aim to keep the skin clean, dry, and free from excessive moisture to prevent maceration.
D. Massaging bony prominences is not recommended as a preventive measure for pressure ulcers. In fact, massaging these areas can increase the risk of tissue damage due to friction and shearing forces. The focus should be on relieving pressure through proper positioning and support surfaces rather than massage.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk for aspiration while eating? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is A

Explanation

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