Chapter 18 Pressure Ulcer Care

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Chapter 18  Pressure Ulcer Care

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

MULTIPLE CHOICE

1. The nurse is turning a patient when she notices an area with nonblanchable redness over the patient’s coccyx. The patient complains of pain at the site, and the site does feel cooler than the areas immediately around the site. The nurse recognizes that this patient has developed:
a.
a stage I pressure.
b.
a stage II pressure.
c.
an unstageable pressure.
d.
deep tissue injury.

ANS: A
The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler as compared with adjacent tissue. Stage II pressure ulcers are defined by partial-thickness loss that presents as a shallow open ulcer with a red or pink wound bed, without slough. They also may present as intact or open/ruptured serum-filled blisters. They usually present as shiny or dry shallow ulcers without sloughing or bruising. Unstageable pressure ulcers are characterized by full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore the stage, cannot be determined. Deep tissue injury usually is characterized by purple or maroon localized areas of discolored intact skin or blood-filled blisters caused by damage to underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared with adjacent tissue. The wound may further evolve and become covered by thin eschar.

DIF: Cognitive Level: Analysis REF: Text reference: p. 435
OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Stage I Pressure Ulcer
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. In a patient with a stage II pressure ulcer, the nurse describes the wound as:
a.
superficial blistering.
b.
nonblanchable redness.
c.
loss of skin without bone exposure.
d.
loss of skin with exposed muscle.

ANS: A
A stage II pressure ulcer is defined by partial-thickness loss presenting as a shallow open ulcer with a red to pink wound bed, without slough. It also may present as an intact or open/ruptured serum-filled blister. It usually presents as a shiny or dry shallow ulcer without sloughing or bruising. The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler as compared with adjacent tissue. Stage III pressure ulcers involve full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present in some parts of the wound bed.

DIF: Cognitive Level: Analysis REF: Text reference: p. 435
OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Stage II Pressure Ulcer
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure ulcer?
a.
The patient who is bedridden, but who turns himself randomly
b.
The patient whose Braden Scale score is 8
c.
The patient who can ambulate to the bathroom independently
d.
The patient whose Braden Scale score is 18

ANS: B
Given the overall score on the Braden Scale, the patient will fall within one of these categories: mild risk, 16 to 18; moderate risk, 13 to 14; or high risk, 9 or less. Use these risk scores to plan care by looking at the individual risk factors that place the patient at risk and developing a care plan to decrease or eliminate the identified risk factors. Immobility often restricts the patient’s ability to change and control body position, thus increasing pressure over bony prominences. Patients who can turn themselves are at less risk than those who cannot.

DIF: Cognitive Level: Analysis REF: Text reference: pp. 438-439
OBJ: Discuss the risk assessment tools commonly used in assessment of pressure ulcer risk.
TOP: Braden Scale KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

4. Aggressive prevention measures should be implemented for a patient in the general population with a pressure ulcer risk on the Braden Scale of less than or equal to:
a.
16.
b.
18.
c.
20.
d.
24.

ANS: A
Less than or equal to 16 is the risk cut score for the general population when the Braden Scale is used. Less than or equal to 18 is the risk cut score for older adults and black or Latino patients when the Braden Scale is used.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 439
OBJ: Discuss the risk assessment tools commonly used in assessment of pressure ulcer risk.
TOP: Braden Scale KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

5. A patient with anemia is at risk for developing pressure ulcers as a result of which of the following?
a.
Increased sedation
b.
Edematous tissues
c.
Reduced tensile strength
d.
Diminished oxygen to the tissues

ANS: D
Decreased hemoglobin reduces the oxygen-carrying capacity of the blood and the amount of oxygen available to the tissues, thus increasing the risk for pressure ulcers. Anemia does not cause increased sedation, edematous tissue, or reduced tensile strength.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 439
OBJ: Identify risk factors for the development of pressure ulcers.
TOP: Anemia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

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