An elderly female patient who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting
During your assessment of the patient, you find that the ulcer extends into the muscle and bone. At 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...
A woman comes to the clinic, and the nurse believes that she is speaking French. She seems to understand English. A provider will need to complete a physical examination to confirm the health problem
Which of the following actions should be taken by the nurse? a. Ask the client if she prefers a male or female provider b. Ask a female provider to assume care c. Ask the physician provider to see her immediately d. Ask the secretary in the office who speaks French to assist in collecting a health history from the client
A patient, who is experiencing some angina associated with atrial tachycardia, has been placed on verapamil (Calan), a calcium channel blocker
Knowing that this medication blocks the slow calcium channels, thereby depressing phase 4 and lengthening phases 1 and 2 action potential, the nurse should assess this patient for which of the following adverse reactions? A) Bradycardia B) Ventricular tachycardia C) Sudden cardiac death D) Increased cardiac output
Research has shown a psychoneuroimmunologic link between stress, the immune system, and cardiac disease through an effect of which of the following two substances?
a. B lymphocytes and glucocorticoids b. Corticotropin hormone and norepinephrine c. Interleukin-6 and C-reactive protein d. T cells and plasma cortisol
A new instrument has been determined to be highly valid. The nurse researcher should interpret this finding to mean what?
a. It is sensitive but not specific. b. Its use results in minimal random errors. c. It accurately measures level of mentation. d. Determination of interrater reliability is unnecessary.