An elderly female patient who is bedridden is admitted to the unit because of a large pressure ulcer. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. What stage would document this ulcer?
A) I
B) II
C) III
D) IV
Ans: D
Feedback: Stage III and IV pressure ulcers are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure ulcers must be cleaned (débrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.
You might also like to view...
While assessing the development of a 9-month-old infant, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. The nurse is determining whether the infant has developed:
1. Object permanence. 2. Centration. 3. Transductive reasoning. 4. Conservation.
At what stage is the adolescent considered to be,according to Freud's theory?
a. Conceptual b. Genital c. Glandular d. Pubertal
The nurse is providing care to a client who is newly diagnosed with human immunodeficiency virus (HIV). Which statements by the nurse could inhibit the development of a therapeutic communication with this client?
Select all that apply. A) "I am so happy today! I found out that I got accepted into nurse practitioner school, isn't that great?" B) "Well, I guess your homosexual lifestyle finally caught up to you, huh?" C) "One of my cousins has AIDS. It is hard to watch him die." D) "Tell me your feelings about the diagnosis." E) "Perhaps you would like to talk about the new medications that you have been prescribed?"
The client who was treated for a "strep" throat 3 weeks ago has a recurrence of the strepto-coccal infection
What additional assessment data should be obtained to determine whether the client has experienced any complications from this ongoing infection? A. Ophthalmoscopic examination of the eye B. Blood pressure in both arms C. Sputum specimen D. Urinalysis