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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A patient's last bowel movement being 4 days ago does not directly increase their risk of pulmonary embolism (PE). While constipation can be a risk factor for deep vein thrombosis (DVT), which can lead to PE, it is not a significant risk factor on its own.
It's important to assess for other risk factors for DVT, such as immobility, recent surgery, or a history of blood clots, in conjunction with constipation.
Choice C rationale:
A platelet count of 45,000/mm^3 is low (thrombocytopenia), but it does not directly increase the risk of PE.
In fact, a low platelet count can sometimes hinder clot formation. However, it's important to monitor patients with thrombocytopenia for bleeding risks, as they may be more prone to bleeding complications.
Choice D rationale:
While receiving a transfusion of two units of packed red blood cells can increase blood viscosity, which could theoretically slightly increase the risk of PE, it is not a major risk factor.
Patients who receive transfusions are often already at an elevated risk of PE due to other underlying conditions or surgeries. It's essential to assess for other risk factors in these patients.
Correct Answer is D
Explanation
Choice A rationale:
Soaking the wound in an Epsom salt solution is not recommended for abscessed wounds. While Epsom salt has some potential benefits for wound healing, such as reducing inflammation and drawing out fluids, it can also be irritating to the skin and may actually worsen the abscess. Additionally, there's a risk of introducing bacteria from the Epsom salt into the wound, which could lead to further infection.
Choice B rationale:
Administering warm water sitz baths is not directly applicable to an abscessed leg wound. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or postpartum discomfort. They may help to soothe and cleanse the affected area, but they would not be effective in treating an abscess on the leg.
Choice C rationale:
Applying cold moist compresses is not the most appropriate intervention for an abscessed wound. Cold compresses can help to reduce pain and inflammation, but they can also constrict blood vessels and potentially hinder the healing process. Warm compresses are generally preferred for abscesses because they can help to promote drainage and healing.
Choice D rationale:
Applying warm moist compresses is the most appropriate nursing intervention for an abscessed leg wound. Warm compresses have several beneficial effects:
They promote vasodilation, which increases blood flow to the area and helps to deliver white blood cells and other healing agents to the site of infection.
They help to soften and loosen hardened pus, making it easier for the abscess to drain.
They provide a moist environment that promotes healing and prevents the wound from drying out. They can help to reduce pain and inflammation.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.