The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?
Stage 1 pressure ulcer
Stage 4 pressure ulcer
Stage 2 pressure ulcer
Stage 3 pressure ulcer
The Correct Answer is D
Rationale:
A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.
B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.
C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.
D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.
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View Related questions
Correct Answer is A
Explanation
Rationale:
A. Using a moisturizer after cleaning helps keep the skin hydrated, preventing dryness and cracking, which can increase the risk of infection.
B. Allowing the skin to air dry can lead to excessive dryness, especially in vulnerable areas, potentially compromising the skin’s integrity.
C. Rubbing the skin firmly can cause irritation, damage, and increased risk of skin breakdown, particularly in individuals with fragile skin.
D. Washing the skin daily with hot water can strip the skin of natural oils, leading to dryness and irritation, which increases the risk of infection. Warm water should be used instead.
Correct Answer is C
Explanation
Rationale:
A. A guaiac test does not check for parasites. Tests for parasites typically involve microscopic examination of the stool or other specialized tests.
B. Steatorrhea refers to fat in the stool, and this is detected through tests that measure fat content in the stool, not a guaiac test.
C. A guaiac test is specifically used to detect occult (hidden) blood in the stool, which can indicate gastrointestinal bleeding, polyps, or colorectal cancer.
D. Bacteria in the stool is detected through stool cultures, not a guaiac test.