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

Answer and Explanation

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.

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Correct Answer is B

Explanation

An appropriate outcome statement for a client with a discharge goal of improved mobility should be specific, measurable, achievable, relevant, and time-bound. In this case, the outcome statement "Client will ambulate without a walker by 6 weeks" meets these criteria. It specifies the desired outcome (ambulating without a walker), provides a measurable goal (6 weeks), is achievable and relevant to the client's goal of improved mobility, and includes a time frame for achieving the goal. The other statements are not specific or measurable enough to be considered appropriate outcome statements.

A. There is one best intervention for each goal/outcome. B. Actions should address the etiology of the nursing diagnosis. C. Interventions should be "doing" not just monitoring. D. Always select independent interventions when possible.

Correct Answer is B

Explanation

When selecting interventions for a care plan, the nurse should consider several principles. One important principle is that actions should address the underlying cause (etiology) of the nursing diagnosis. By addressing the root cause of the problem, interventions can be more eﬀective in achieving the desired outcomes. There is not necessarily one "best" intervention for each goal or outcome, as diﬀerent clients may have diﬀerent needs and respond diﬀerently to interventions. Interventions can include both "doing" actions and monitoring, and both independent and collaborative interventions may be appropriate depending on the situation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately?

Correct Answer is B

Explanation

Which of the following principles does the nurse use in selecting interventions for the care plan?

Correct Answer is B

Explanation

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