An older adult patient with diabetes recently moved into an assisted living apartment to have assistance with bathing and housework. During a bath, the assistive nursing personnel noticed that there was a large blister on the patient's right heel
The patient denies knowledge of having injured self. It was reported to the nurse who correctly documented it as what stage of a pressure ulcer? a. Stage I
b. Stage II
c. Stage III
d. Stage IV
B
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister
Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling
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The nurse classifies which of the following families as a blended family?
1. Parents of different races and their biological offspring 2. One or both parents with children from a previous relationship 3. Three or more generations of a family living in the same household 4. Adults and children living in the same household who are not biologically related
A patient with a serious illness is being cared for in a CCU. Considering energy expenditure during illness and the potential for healing, what is most appropriate nursing action?
A) Maintain complete bed rest with minimal activity B) Ensure complete pharmacological sedation C) Limit visits to immediate family only D) Facilitate nutrition assessment and delivery
When a child is hospitalized, one component of their plan of care is the use of therapeutic play. This care is often provided by a(n) _____________
Fill in the blank(s) with correct word
Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion or both
Over time diabetes causes significant maternal changes in the microvascular and macrovascular circulations. These complications include (select all that apply) a. Atherosclerosis b. Retinopathy c. IUFD d. Nephropathy e. Neuropathy