While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?
Stage II pressure ulcer
Stage IV pressure ulcer
Stage I pressure ulcer
Stage III pressure ulcer
The Correct Answer is A
A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
All of the options listed (Willing to learn from clients, Motivated to provide to the best of her abilities, Aware of how beliefs and values influence others, Accepting responsibility for one's actions, and advocating for all clients) are attributes of a professional nurse. A professional nurse should be willing to learn from their clients and be motivated to provide the best care possible. They should also be aware of how their beliefs and values can influence others and accept responsibility for their actions. Additionally, a professional nurse should advocate for all clients.
Correct Answer is ["C","D"]
Explanation
If a visitor in the dining room at the hospital has a forceful cough, the nurse should first allow the visitor to continue coughing. Coughing is a natural reflex that helps clear the airway of foreign objects or mucus. The nurse should also assess the effectiveness of the cough. If the cough is weak or ineffective, further intervention may be necessary.
Starting cardiopulmonary resuscitation (CPR) or performing the Heimlich maneuver would only be appropriate if the visitor is choking and unable to breathe. Assisting the client to a sitting position on the floor may not be necessary and could potentially cause harm.
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