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 ["C","D"]
Explanation
When planning interventions to promote a client's appetite, it would be important to include providing a tidy, clean environment that is free of unpleasant sights or odors and encouraging or providing oral hygiene after mealtime in the client's plan. A pleasant and comfortable environment can help stimulate the appetite and make mealtime more enjoyable. Good oral hygiene can also help improve the taste of food and promote appetite. Unpleasant or uncomfortable treatments should not be performed before or after a meal as they may decrease the client's appetite. Providing unfamiliar food may not be helpful in promoting appetite as clients may prefer familiar and comforting foods.
Correct Answer is C
Explanation
Public health agencies are responsible for protecting and improving the health of communities. They are often funded by government grants and work to prevent the spread of communicable diseases through measures such as vaccination programs, disease surveillance, and public education campaigns. Surgery can be performed in a variety of healthcare settings, not just hospitals. Skilled nursing extended care facilities provide care for individuals who require ongoing medical support, not just older adults whose insurance no longer covers hospital stays. Hospitals provide a range of services, including acute inpatient care as well as outpatient and emergency services.
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