Author Question: When a patient has full-thickness loss but the depth is unknown, how should the nurse classify this ... (Read 39 times)

kwoodring · **on:** Jul 22, 2018

When a patient has full-thickness loss but the depth is unknown, how should the nurse classify this pressure ulcer?

a. Stage/Category III
b. Unstageable
c. Suspected deep tissue injury
d. Stage/Category IV

Question 2

Upon assessment, the nurse finds that a patient has a heart rate of 66 beats per minute, a respiratory rate of 12 breaths per minute, and a blood pressure of 120/80 mm Hg. The nurse obtained which type of data?

a. Personal
b. Demographic
c. Subjective
d. Objective

kjo;oj · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Unstageable: Full-thickness tissue loss-depth unknown.
Stage/Category III: Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Suspected Deep Tissue InjuryDepth Unknown: Purple or maroon localized area of discolored intact skin or blood-filled blister owing to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared with adjacent tissue.
Stage/Category IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling.

Answer to Question 2

D
Objective data are observations or measurements of a patient's health status. Personal and demographic data refer to patient's name, age, sex, and so on. Subjective data are patients' verbal descriptions about their health problems. Demographic data includes birth, gender, address, family members' names and addresses.