Which term should a nurse use to describe a deep decubitus ulcer on a patient’s heel that is covered in thick necrotic tissue?

Indurated

Fluctuant

Unstageable

Macerated

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Indurated describes tissue that is hardened and thickened, typically due to inflammation or fibrosis. While a decubitus ulcer with thick necrotic tissue may feel firm to the touch, induration does not accurately capture the extent of tissue damage and depth of the wound.

Indurated tissue often feels leathery or stiff, while necrotic tissue can be more varied in texture, ranging from dry and crusty to soft and sloughy.

Additionally, induration can occur in wounds that are not full-thickness ulcers, such as pressure injuries that have not yet progressed to the point of tissue loss.

Choice B rationale:

Fluctuant describes a fluid-filled cavity beneath the skin. While a decubitus ulcer with thick necrotic tissue may have some underlying fluid, it would not typically be described as fluctuant.

Fluctuance is more characteristic of abscesses or other fluid collections that have a distinct, palpable pocket of fluid.

The presence of thick necrotic tissue in a decubitus ulcer can obscure the presence of any underlying fluid, making it difficult to assess for fluctuance.

Choice D rationale:

Macerated describes skin that is softened and broken down due to prolonged exposure to moisture. While maceration can occur in the surrounding skin of a decubitus ulcer, it does not accurately describe the ulcer itself.

Maceration is typically seen in areas where skin folds rub together, such as the groin or armpits, and is often associated with incontinence or excessive sweating.

The presence of thick necrotic tissue in a decubitus ulcer indicates a more advanced stage of tissue damage that is not simply due to moisture exposure.

Choice C rationale:

Unstageable is the most accurate term to describe a decubitus ulcer with thick necrotic tissue because it indicates that the extent of tissue damage cannot be fully assessed.

Thick necrotic tissue obscures the base of the wound and the surrounding tissue, making it impossible to determine the depth of the ulcer or the extent of undermining.

This lack of visibility prevents accurate staging of the ulcer using the traditional pressure ulcer staging system, which categorizes ulcers based on their depth and extent of tissue involvement.

Therefore, unstageable is the most appropriate term to describe a decubitus ulcer with thick necrotic tissue.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Shearing force is the primary factor that contributes to the formation of pressure injuries when a patient's body slides downward. It occurs when two surfaces move in opposite directions, causing stress and strain on the tissues between them.

Compression of Tissues: When the patient's body slides downward, the skin and underlying tissues are compressed between the bony prominences (such as the sacrum or heels) and the surface of the bed. This compression restricts blood flow to the area, depriving the tissues of oxygen and nutrients.

Tissue Stretching and Tearing: As the body slides, the skin and underlying tissues are also stretched and pulled in opposite directions. This shearing force disrupts the normal alignment of cells and tissues, leading to microscopic tears and damage.

Impaired Blood Flow: Shearing force further compromises blood flow by stretching and compressing blood vessels. This reduces the delivery of oxygen and nutrients to the tissues, while also hindering the removal of waste products.

Tissue Damage and Necrosis: The combination of compression, stretching, and impaired blood flow leads to cell death and tissue necrosis. This is the hallmark of pressure injuries, which can range from superficial blisters to deep ulcers that extend into muscle and bone.

Factors that Increase Shearing Force: Certain factors can increase the risk of shearing force and pressure injury development, including:

Increased moisture (from sweat or incontinence) Decreased mobility

Poor skin integrity

Malnutrition

Friction from bedsheets

In conclusion, shearing force is the main factor that contributes to pressure injury formation when a patient's body slides downward. It disrupts blood flow, damages tissues, and can lead to significant wounds.

A. Alopecia and diaphoresis B. Heartburn and flatulence C. Nausea and constipation D. Itchy rash and difficulty breathing

Correct Answer is D

Explanation

Choice A rationale:

Alopecia (hair loss) and diaphoresis (excessive sweating) can be side effects of certain medications, but they are not typically associated with allergic reactions.

Alopecia is often a delayed side effect of medications, meaning it can take weeks or months to develop after starting a medication. It is usually caused by the medication interfering with the normal hair growth cycle.

Diaphoresis can be a side effect of medications that affect the nervous system, such as antidepressants and anti-anxiety medications. It can also be a side effect of medications that cause fever, such as antibiotics.

Choice B rationale:

Heartburn and flatulence are common side effects of many medications, especially those that affect the digestive system.

Heartburn is a burning sensation in the chest that is caused by stomach acid refluxing back up into the esophagus. It is often triggered by eating certain foods, lying down after eating, or taking certain medications.

Flatulence is the release of gas from the intestines. It is often caused by eating foods that are difficult to digest, such as beans and cabbage. It can also be a side effect of medications that slow down the digestive system.

Choice C rationale:

Nausea and constipation are also common side effects of many medications.

Nausea is a feeling of sickness or unease in the stomach that can lead to vomiting. It is often caused by medications that irritate the stomach lining or that stimulate the vomiting center in the brain.

Constipation is a condition in which bowel movements are infrequent or difficult to pass. It is often caused by medications that slow down the movement of food through the intestines.

Choice D rationale:

Itchy rash and difficulty breathing are classic symptoms of an allergic reaction.

An allergic reaction occurs when the body's immune system overreacts to a substance that it perceives as a threat. This can cause a variety of symptoms, including itchy rash, difficulty breathing, swelling, hives, and anaphylaxis.

Itchy rash is a common symptom of allergic reactions to medications. It is often caused by the release of histamine, a chemical that is involved in the body's inflammatory response.

Difficulty breathing is a serious symptom of an allergic reaction that can be life-threatening. It is often caused by swelling of the airways, which can restrict airflow.

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

Which term should a nurse use to describe a deep decubitus ulcer on a patient’s heel that is covered in thick necrotic tissue?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which factor contributes to the formation of a pressure injury when a patient’s body slides downward to the foot of the bed?

Correct Answer is A

Explanation

The nurse administers a medication to the patient.Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?

Correct Answer is D

Explanation

The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.Which term will the nurse use to describe this area?

If a patient’s insurance company declines to cover the cost of a brand-name drug, which version of the drug will the patient likely receive instead?

The nurse notes that the patient is scratching and has hives 2 hours after receiving a dose of antibiotic medication.The patient soon starts having difficulty breathing and his blood pressure drops. What is the correct analysis of the patient’s condition?

The nurse is scheduled to administer the patient’s next dose of vancomycin at 9:30 a.m. At what time should the nurse draw the patient’s blood to check the trough vancomycin level?

Which assessment charting indicates that the wound is healing by primary intention?

Which term should a nurse use to describe a deep decubitus ulcer on a patient’s heel that is covered in thick necrotic tissue?

The nurse administers a medication to the patient. Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?

The nurse is to administer enoxaparin 40 mg subcutaneously to the patient. Which technique is correct?