A nurse is assessing a pressure ulcer in a pediatric client. The ulcer appears as a deep crater into the subcutaneous tissue, but does not extend to the adjacent muscle, bone, or supporting tissue
As what stage would this nurse classify the ulcer? 1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4
3
Rationale:
1. This is a Stage 3 ulcer. Stage 1 is nonblanchable erythema of intact skin that does not resolve within 30 minutes of pressure relief. Stage 3 is a full-thickness injury through the dermis and into the subcutaneous tissue; a deep crater with or without undermining of adjacent tissue.
2. This is a Stage 3 ulcer. Stage 2 is a partial-thickness injury, such as a blister, involving the epidermis or partly into the dermis. Stage 3 is a full-thickness injury through the dermis and into the subcutaneous tissue; a deep crater with or without undermining of adjacent tissue.
3. This is a Stage 3 ulcer. Stage 3 is a full-thickness injury through the dermis and into the subcutaneous tissue; a deep crater with or without undermining of adjacent tissue.
4. This is a Stage 3 ulcer. Stage 4 involves extensive tissue destruction through the subcutaneous tissue and fascia that can extend to the muscle, bone, or supporting tissues. Stage 3 is a full-thickness injury through the dermis and into the subcutaneous tissue; a deep crater with or without undermining of adjacent tissue.
You might also like to view...
Which of the following is most likely to be true about caring for an older African-American patient?
a. The patient can expect to find support from his church after discharge. b. During a physical assessment, an exami-nation of the interior of the patient's mouth with adequate light is important. c. The patient may follow hot-cold beliefs. d. African Americans may avoid eye contact when interacting with others.
To better ensure successful rehabilitation from substance abuse, it is essential that the patient, family, and medical professional:
a. collaborate on goals for treatment. b. be alert to relapse. c. agree that all drugs and paraphernalia be discarded. d. support commitment to a 12-step program.
Which of the following may be present in the patient with significant fluid volume overload? (Select all that apply.)
a. S3 or S4 may develop. b. Distention of the hand veins will disappear if the hand is elevated. c. When testing the quality of skin turgor, the skin will not return to the normal position for several seconds. d. Tachycardia with hypotension may be present. e. Dependent edema may be present.
The ________ is the entrance of the uterus.
Fill in the blank(s) with the appropriate word(s).