Which manifestation would the nurse associate with a Stage 2 pressure injury?

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Which manifestation would the nurse associate with stage 2 pressure injury?
What does a Stage 2 pressure injury look like?
How Deep Is a Stage 2 pressure injury?
Is Stage 2 pressure injury superficial?

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Stack #223454

Question	Answer
Which one of the following statements is a requirement for Medicare home healthcare reimbursement?	The patient must be essentially homebound.
In general, how does home care nursing compare with hospital-based nursing?	In the home, care must be adapted to the patient's schedules and customs.
Although the home care nurse follows an established plan of care, he or she is more independent in what role?	Assuming responsibility for decision making
Although all of the following skills are important, what would be the most important to effective coordination of care and services?	Effective communication
Which of the following activities would the nurse do in the pre-entry phase of the home visit?	Collect information and schedule a visit
Before washing her hands, what might a home health nurse ask or say to the patient?	“I need to wash my hands. May I use your bathroom?”
What one activity is most important in preventing infection when providing home care?	Performing hand hygiene before and after care
How often must a home care nurse document progress notes?	At each visit
When developing a plan of care for an older patient, the nurse pays special attention to the patient's skin based on an understanding of which of the following?	The skin becomes increasingly dry as we age.
Which intervention would be appropriate to include in the plan of care for a patient wearing antiembolism stockings?	Measuring legs before applying stockings to ensure proper fit.
During a bath, the nurse observes that a patient has dry skin. Which action would be best?	Use an emollient on the dry skin.
Which recommendation by the nurse to an adolescent patient with acne would be most appropriate?	Wash the skin frequently.
The nurse observes a marked inflammation of the gums, and recession and bleeding of the gums and documents this observation using which term?	Periodontitis.
Periodontitis.	is a marked inflammation of the gums, whereas caries refers to the presence of tooth decay.
Cheilosis.	ulceration of the lips.
glossitis.	inflammation of the tongue.
Which action would be the priority when administering oral care to a dependent patient?	Wearing disposable gloves.
Mr. James has an eye infection with a moderate amount of discharge. Which action would be most appropriate for the nurse to use when cleaning his eyes?	Positioning him on the same side as the eye to be cleansed.
Which of the following interventions would the nurse include in the plan of care when providing foot care to an older patient?	Bathing the feet at least daily.
Providing perineal care to a patient requires which of the following?	Using a clean portion of the washcloth for each stroke.
A nurse is caring for an 80 year who requires total assistance with his personal and oral hygiene. He is thin, has few visitors, and prefers to remain in bed in a semisitting position. Which nursing diagnosis would the nurse identify as the priority?	Risk for Impaired Skin Integrity related to immobility.
An older patient with an unsteady gait requests a tub bath. Which of the following actions would be most appropriate?	Assist the patient in and out of the tub to prevent falling.
During morning care, the patient asks the nurse to shave him with a disposable razor. Before shaving him, the nurse should:	Check to see if the patient is taking anticoagulants.
To remove gas-permeable contact lenses from an unresponsive patient, the nurse would:	Ensure that the lens is centered on the cornea before gently manipulating the lids to release it
The nurse is about to bathe a female patient who has an intravenous line in place, and needs to remove her gown. The nurse should:	Thread the bag and tubing through the gown sleeve, keeping the line intact.
When making an occupied bed, which of the following is most important for the nurse to do?	Use a bath blanket or top sheet for warmth and privacy.
Noncompliance with a therapeutic regimen can be a significant problem for elderly people. One of the common reasons for noncompliance in the elderly is:	Inadequate financial resources.
A nurse is preparing to teach a 45-year-old patient with asthma how to use his inhaler. One of the best methods to teach the patient this skill is by:	Demonstration.
A nurse has taught a diabetic patient how to administer his daily insulin. The nurse should evaluate the teaching learning process by:	Deciding if the learning outcomes have been achieved.
A nurse is using the health belief model to assess a patient. Using this model, the nurse should begin to understand:	Whether the patient is willing to take actions to support health.
Nurses play a vital role in patient teaching because of their:	Expertise in healthcare.
A nurse instructs a group of parents about how to make their home safe for their toddlers. This is an example of teaching aimed toward:	Preventing illness.
When preparing a health promotion program for patients in an adult day-care center, the first step the nurse must take is to:	Assess the patients' learning needs and learning readiness.
When using facts from the patient's medical record as part of the necessary information to assess learning needs, the nurse is using which type of data source?	Secondary.
The primary purpose of a contractual agreement between nurses and patients when beginning a teaching plan is to:	Motivate both the patient and nurse to do what is necessary to meet the patient's learning outcomes.
One of the best ways to affirm the efforts of patients who master new knowledge, attitudes, or skills is through:	Positive reinforcement.
After a surgical incision, a patient often has an elevated body temperature and generalized malaise. These manifestations most often occur during which phase of wound healing?	Inflammatory.
Systemic manifestations.	occur as a result of the inflammatory response to the altered skin and tissue integrity. Systemic manifestations do not usually continue into the fibroplasia and maturation phases of wound healing.
Which term would the nurse use to document wound drainage that is thick, odorous, and green?	Purulent.
Purulent drainage.	is the result of an infection and is thick, odorous, and colored.
A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. You immediately report this as:	Wound dehiscence with evisceration.
wound complications of dehiscence and evisceration.	manifested by a wound that opens up and has viscera protruding.
Sara Liu, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, Sara says, “I am so ugly now.” Based on this statement, what nursing diagnosis would be most appropriate?	Disturbed Body Image.
Which action is believed to be most useful in preventing wound infections?	Performing careful hand hygiene.
During a dressing change, inspection of the wound reveals what appears to be reddish-pink tissue in the wound. The nurse interprets this as most likely indicating:	Granulation tissue.
Granulation tissue.	is new tissue composed of many small blood vessels, is pinkish red, and fills an open wound when it starts to heal.
Which intervention would the nurse expect to use for applying moist heat?	Sitz bath.
When assessing a patient at risk for pressure ulcer formation, which site would the nurse identify as being most common?	Sacrum.
When explaining about factors contributing to pressure ulcers, which factor would the nurse describe as key?	Pressure.
Which hospitalized patient is most at risk for a pressure ulcer?	A 70-year-old patient with a fractured hip.
After an initial assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer is classified as:	Stage II.
stage II pressure ulcer.	is superficial and presents clinically as an abrasion, ulcer, or shallow crater.
An older confused patient sits and slumps in her chair most of the day. She is most likely to develop a pressure ulcer because of:	Shearing forces.
The nurse assesses a stage III pressure ulcer manifested as:	An open lesion with subcutaneous tissue exposed.
stage III pressure ulcer.	an open lesion that exposes subcutaneous tissue.
stage I pressure ulcer.	Redness that persists.
stage II pressure ulcer.	a reddened area that has an abrasion.
stage IV pressure ulcer.	necrotic area extending through the fascia to the bone.
Which action would be a priority in preventing a patient from developing a pressure ulcer?	Using a mild cleansing agent when cleansing the skin.
Which treatment would the nurse expect to institute for a patient with a stage II pressure ulcer?	A moisture-retentive dressing.
When describing the strong, flexible, inelastic fibrous bands and flattened sheets of connective tissue that attach muscle to bone, the nurse would refer to these as:	Tendons.
Ligaments.	bind joints together and connect bones and cartilage, whereas cartilage.
Cartilage.	is nonvascular connective tissue found in the joints as well as in the nose, ear, thorax, trachea, and larynx.
Joints.	are areas in which one bone comes into close contact with another bone.
The underlying rationale for nurses to spread their feet apart when they prepare to help raise a patient from a chair would be to:	Provide a wide base of support.
A patient performs rehabilitative exercises with resistance after a knee injury. The nurse interprets this type of exercise as which of the following?	Isokinetic.
isotonic exercise.	involves muscle shortening and active movement.
Isometric exercise.	involves muscle contraction without shortening, and aerobic exercise.
Aerobic exercise.	is sustained muscle movements that increase blood flow, heart rate, and metabolic demand for oxygen over time, promoting cardiovascular conditioning.
Which of the following would the nurse expect to assess when a patient experiences a greater breakdown of protein than that which is manufactured?	Negative nitrogen balance.
Contractures.	are permanent contraction states of muscles.
osteoporosis.	involves bone demineralization.
An immobile patient experiences multiple urinary tract infections. Urinary bacteria are more likely to grow when urine is	Alkaline.
urine.	Normally urine is acidic.
Mr. Brown is experiencing some difficulty breathing. The nurse most appropriately assists him into the	Fowler's position.
While doing range-of-motion exercises with a patient who is bedridden, the nurse is aware that	Each joint is exercised to the point of resistance but not pain.
The nurse is assisting a patient with conditioning exercises to prepare for ambulation. The nurse correctly instructs the patient to	Breathe in and out smoothly during quadriceps drills.
In many situations, a patient has sufficient strength to walk if he or she can	Raise the foot off the bed 1 inch.
Mrs. Eden tells the nurse she feels faint while walking in the corridor with the nurse. The nurse	Guides her to a nearby chair, easing her onto it to rest
When using a cane for maximal support, the nurse is aware that the patient should	Distribute weight evenly between the feet and the cane
One technique the nurse can use when measuring a patient for axillary crutches is	Measure from axilla to heel while the patient is lying on his back in bed with his shoes on and add 1 inch
When using the swing-through crutch gait, the patient should	Bear weight on the unaffected foot.
When working with an older patient to develop an exercise program, the nurse would recommend	Obtaining medical clearance before beginning the program
A bedridden patient who is blind is admitted to a healthcare facility from his or her home with pressure ulcers on the sacral area. Which nursing diagnosis would be a priority?	Impaired Skin Integrity related to immobility
In reviewing a client's record, the nurse correlates the ABCD method of assessing skin lesions for cancer to the following characteristics of the lesions. (Please supply fill-in-the-blank answers separated by commas and spaces;	Asymmetry, border, color, diameter.
In assessing skin color, the nurse correlates the darkness of the skin with:	Size of melanocytes.
In providing teaching to a client undergoing excisional biopsy, the nurse includes which of the following statements?	"Administration of local anesthetic agents may cause burning."
The nurse assesses for jaundice in dark-skinned clients by examining the:	Oral mucosa.
The nurse assesses the skin turgor of the older client on the:	Forehead.
The nurse correlates which clinical manifestations as integumentary changes associated with age?	Decreased thickness of epidermal layer.
The nurse notes small, firm, elevated lesions less than 1 cm in diameter and documents these as:	Papules.
The nurse recognizes that the final synthesis of vitamin D occurs primarily in the:	Dermis.
A client with pruritus associated with hepatitis is being cared for by an RN and LPN team. Which of these nursing activities will be best for the RN to delegate to the LPN?	Administer an antihistamine to the client at bedtime. (LPNs are familiar with safe administration of medications, including assessment for medication effectiveness and adverse effects. The other activities are higher level and should be done by an RN.)
A long-term care client who has had an excisional biopsy of a skin lesion in the same-day surgery unit is ready for discharge. Which nursing activity is most appropriate for the RNA resident in a long-term care facility is assessed by the RN and areas of	Apply an antibiotic ointment and place a sterile dressing on the incision.
The home health RN is doing an intake assessment on a client who had a recent shave biopsy of a basal cell carcinoma located on the client’s cheek. Which statement by the client may indicate the greatest need for client teaching?	“I have been working in my garden for several hours every day.”
The staff mix available for the medical-surgical unit includes RNs, LPNs, and nursing assistants. Which of the following clients will be most appropriate to assign to an experienced LPN?	A 26-year-old client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road
A client with cellulitis in the left lower leg is admitted to the medical unit. When making assignments, which client would be best to combine with this newly admitted client?	A 23-year-old client who is being evaluated for possible surgical excision of a cyst
The RN and nursing assistant are caring for a group of clients as a team. Which task can the RN assign to the nursing assistant?	Applying a barrier ointment after cleaning the skin of an incontinent client.
The RN is working with an LPN in the home health agency. Which of the following client interventions can the RN delegate to the LPN?	Doing a sterile dressing change for a client who had an excision of a malignant melanoma a week ago and was assessed by the RN on the third postoperative day.
You are the nurse manager for a long-term care facility. Which of these clients would be best to assign to a nursing assistant?	A client who requires repositioning every 2 hours to minimize the risk for skin breakdown
You are working in the same-day surgery unit and are assigned to care for all of the following clients. Which client should you assess first?	A client who has had rhinoplasty and is swallowing frequently.
In assessing the client with cellulitis of the lower extremity, the nurse correlates which clinical manifestations to this skin disorder? (Choose all that apply.)	Warm, Redness, Edema.
Clients with which dietary deficiency are at greatest risk for pressure ulcer development?	Protein.
In caring for a client with a stage III pressure ulcer, the nurse is aware that definitive treatment requires which of the following?	Antibiotic therapy.
In documenting the stage of a pressure ulcer, the nurse identifies the wound with full thickness skin and bone involvement as:	Stage IV
In educating a client about skin cancer prevention, the nurse includes which of the following statements?	"Avoid sun exposure between 11 AM and 3 PM.
In evaluating the effectiveness of interventions for pressure management, which of the following diagnostic results would indicate client progress?	Increased serum albumin.
In reviewing teaching to a client with pediculosis, it is important that the nurse include which of the following statements?	"Everyone in your family needs to be assessed and possibly treated."
In teaching a client with loss of sensation and movement in the lower extremities secondary to spinal cord injury, it is important for the nurse to teach which of the following prevention strategies?	Lift hips off the chair at least every 30 minutes.
The nurse correlates which clinical manifestations with melanoma?	Lesion has variegated colors, usually red, blue, and white.
The nurse correlates which rationale to the use of corticosteroids for the client with psoriasis?	Decreases cell division of skin cells.
The nurse teaches the client receiving ultraviolet therapy for psoriasis that this therapy:	Destroys fast-dividing cells responsible for psoriasis.
The nurse teaches the client with dry skin the importance of applying skin creams and lotions to:	Slightly damp skin to seal in water.
The nurse understands that deep tissue wounds, like chronic pressure ulcers, heal by:	Second intention.
Which of the following statements by the client with psoriasis indicates that the teaching about this condition has been effective?	“Stress can make me have more flare-ups.”
Mrs. Simpson is a 78-year-old woman being seen in the medical clinic today for a yearly checkup. She is presenting today with complaints of joint pain and stiffness. Select all of the musculoskeletal changes associated with aging.	A.Decreased bone density,B.Synovial joint cartilage can become less elastic, C. Increased bone prominence, E.Muscle atrophy.
Shannon is teaching her client Mary Ellen the follow-up care to expect after her musculoskeletal diagnostic testing. Which statement, if made by the client, demonstrates a good understanding of the follow-up to her diagnostic procedure?	"I may develop blood under my skin at the needle sites."
When evaluating Mrs. Simpson's musculoskeletal history, the nurse uses Gordon's Functional Health Patterns. Which statement reflects a correct understanding of this tool by the nurse?	Level IV: is dependent and does not participate
When teaching a group of third year nursing students about musculoskeletal assessments, Mrs. McLaughlin covers a variety of topics. Which statement, if made by one of the students, indicates that further teaching is necessary?	“Scoliosis is a common finding in pregnancy and in abdominal obesity.”
A nurse is ambulating a patient who catches her foot on a bedpost and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?	The nurse should gently slide the patient down his body to the floor.
A patient who has a cast on his arm is experiencing pain and tightness in his arm, along with sluggish capillary refill. The nurse suspects compartment syndrome. Which of the following would be the appropriate intervention for this patient?	Adjust the arm so that it is no higher than the heart level and call the physician immediately.
Why is it important for the nurse to teach and role model proper body mechanics?	to promote health and prevent illness
A nurse is assessing the muscles of an older adult. What will be assessed?	mass, tone, strength
Bedrest, with resultant immobility, affects the whole body. What is one effect on the musculoskeletal system?	increased risk for contractures
A middle-aged man walks 2 miles each day. What type of exercise is he getting by this activity?	isotonic
Of the following guidelines, which would not be recommended to a person who has sustained an orthopedic injury during exercise?	warmth
An immobile person has decreased movement of respiratory secretions. What condition is a greater risk as a result?	respiratory tract infection
At what time would a nurse assess the gait of an ambulatory patient?	when the patient walks into the room
A nurse is caring for a comatose patient. What can happen to the feet if they are unsupported in the dorsiflexed position?	plantar flexion and foot drop
A nurse is assessing the skin of a patient with dry skin and notices several areas of scratches and abrasions. When developing the care plan, which goal would be the most important to include?	decrease the risk of infection
Which of the following patients would be at greatest risk for injury to the skin and mucous membranes?	77-year-old man with diabetes
A nurse is conducting a health history for a patient with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene?	“Tell me about what you do to take care of your skin.”
A student has been assigned to provide hygiene care to four patients. Which one would require special consideration for perineal care?	middle-aged woman with a Foley catheter
Which of the following statements by a patient would alert the nurse to an increased risk for skin cancer?	“This wart has changed color.”
What are the two major processes involved in the inflammatory phase of wound healing?	blood clotting is initiated, WBCs move into the wound
A nurse is teaching a postoperative patient about essential nutrition for healing. What statement by the patient would indicate a need for more information?	“I will restrict my diet to fats and carbohydrates.”
What intervention should be included on a plan of care to prevent pressure ulcer development in healthcare settings?	implement a turning schedule
A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected?	full-thickness skin loss
A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate?	infection
A patient has a fractured rib and is breathing less often and with less depth because of the pain. The nurse would document this finding using which term?	Hypoventilation
Hyperventilation	is an increased rate and depth of ventilation.
Fremitus	is the vibration of the chest wall that can be palpated.
A pleural friction rub	is a dry grating sound caused by inflammation of pleural surfaces.
When auscultating Mr. Chang's breath sounds, the nurse detects a continuous, musical sound heard on expiration. The nurse identifies this sound as:	Wheezes
Wheezes	are a continuous sound heard on expiration.
Crackles	are not described as squeaky.
Bronchial breath sounds	are normal sounds heard over the trachea.
Air that develops in the pleural space is referred to as:	Pneumothorax
pleural effusion.	Fluid in the pleural space
hemothorax.	Blood collection in the pleural space
Atelectasis	an incomplete expansion or collapse of the alveoli.
When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, the nurse expects that:	The rate will be 2 L/min or less.
Which oxygen delivery device would the nurse expect to use to provide the highest concentration of oxygen to a patient who is breathing spontaneously?	Nonrebreather mask
When teaching a patient about pulse oximetry, which statement would the nurse most likely include in the discussion?	A range of 95% to 100% is considered normal oxygen saturation.
Which action would the nurse include when performing oropharyngeal suctioning on a patient?	Flush the catheter with saline between catheter insertions.
Effective use of a metered-dose inhaler requires that the patient accomplish which action?	Hold the breath for 5 to 10 seconds after inspiration.
Mr. Parks has chronic obstructive pulmonary disease. The nurse has taught him that pursed-lip breathing helps him by:	Decreasing the amount of air trapping and resistance
A patient develops sudden cardiac arrest. What is the critical time that the nurse must keep in mind before irreversible brain damage occurs?	4 to 6 minutes
David White is in the hospital with a medical diagnosis of viral pneumonia. He is receiving oxygen through a simple face mask. The nurse ensures that the mask fits snugly over the patient's face for which reason?	To aid in maintaining expected oxygen delivery
When suctioning a patient through a tracheostomy tube, the nurse was careful not to occlude the Y port when inserting the suction catheter because this would:	Suction out all the carbon dioxide
The nurse follows safe technique when using a portable oxygen cylinder by:	Checking the amount of oxygen in the cylinder before using it
Which blood gas values would the nurse identify as within the normal range?	pH, 7.35 to 7.45; PaCO2, 35 to 45 mm Hg; PaO2, 80 to 100 mm Hg
Abdominal breathing at 30 to 60 breaths/minute with an irregular pattern of rate and depth would closely describe the breathing patterns of what age group?	Infant
As alveoli increase in number and size	the respiratory rate decreases.

Which manifestation would the nurse associate with stage 2 pressure injury?

At stage two, the skin breaks. Sores may appear as an intact blister or as a shallow, open sore. Stage two pressure sores extend into the layers of skin, but you cannot see fat, muscle, or bone through the injury. Stage two pressure ulcers may include reddened or broken skin, an obvious blister, or pus.

What does a Stage 2 pressure injury look like?

At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid.

How Deep Is a Stage 2 pressure injury?

Stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis. This includes intact or ruptured blisters.

Is Stage 2 pressure injury superficial?

The skin appears red in those with lighter skin tones and blue/purple in those with darker skin tones. The skin does not blanch (turn white) when pressed with a finger. Stage 2: This stage involves superficial damage of the skin. The top layer of skin is lost.

Which manifestation would the nurse associate with a Stage 2 pressure injury?

Stack #223454

Which manifestation would the nurse associate with stage 2 pressure injury?

What does a Stage 2 pressure injury look like?

How Deep Is a Stage 2 pressure injury?

Is Stage 2 pressure injury superficial?

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