During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?
a) Stage III
b) Stage II
c) Stage I
d) Stage IV
Answer: A
Learn More :
Principles and Practices of Rehabilitation
- A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care?
- The nurse is evaluating whether or not a patient's walker is the right height for the patient. While the patient's hands are on the hand grip, the nurse assesses the patient's elbows. The nurse determines that the walker is at the right height when the patient's elbows are in which of the following positions?
- A spinal cord injury patient has no awareness of the need to void. This type of incontinence is termed
- A nurse is assisting an 80-year-old patient out of bed for the first time after being on strict bedrest for several days. Which of the following would lead the nurse to suspect that the patient is experiencing orthostatic hypotension?
- A patient is being taught to go down stairs using a cane. The nurse would instruct the patient to do which of the following first?
- Which intervention has the highest priority when providing skin care to a bedridden client?
- A nurse is performing range-of-motion exercises and moves the patient's hand sideways so that the little finger moves toward the forearm. The nurse is performing which of the following?
- When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.
- Which type of scale is used for systematic assessment and quantification of a patient's risk for pressure ulcer?
- A patient who is 5 feet 10 inches tall is being measured for crutches. The nurse determines which crutches as being the appropriate length?
- Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply.
- A patient has a nursing diagnosis of risk for impaired skin integrity related to immobility and diabetes. As part of the plan of care, the nurse plans to reposition the patient frequently. Based on an understanding of positioning and its effects, the nurse identifies which position as preferred to the semi-Fowler's position?
- A nurse is performing range-of-motion exercises with a patient and preparing to hyperextend the hip. The nurse places the patient in which position?
- The nurse is observing a client using a cane to ambulate. Which of the following would require the nurse to intervene?
- A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate?
- The nurse is helping a patient who experiences frequent constipation select his meal choices for the day. Which of the following should the nurse encourage the patient to order?
- The nurse is completing an initial assessment on an elderly patient. When asked about her urinary patterns, the patient states that she can "never get to the bathroom in time." The nurse documents this as which of the following?
- A client with a walker is being discharged from the orthopedic unit to home. The nurse must teach the client how to use a walker properly. Which explanation demonstrates safe walker use?
- A nurse is developing a plan of care for a patient experiencing urinary incontinence and identifies a nursing diagnosis of risk for infection related to urinary incontinence and inadequate bladder emptying. Which of the following would the nurse most likely include as an appropriate fluid to encourage?
- A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?
- A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?
- A nurse has taught a client how to perform quadriceps-setting exercises. The nurse determines that the client has understood the instructions when he demonstrates which of the following?
- The nurse is performing a skin assessment on a bedbound patient who was positioned in a semi-Fowler's position. The nurse notices erythema over the sacrum and repositions the patient to a left recumbent position. The nurse anticipates resolution of the erythema will occur in less than which of the following timeframes?
- Half of all spinal cord injuries are related to
- Students are reviewing information about rehabilitation and brain and spinal cord injuries. They demonstrate understanding of the information when they identify which of the following as being responsible for approximately one-half of all traumatic brain injuries?
If the answers is incorrect or not given, you can answer the above question in the comment box. If the answers is incorrect or not given, you can answer the above question in the comment box.