The nurse is completing a skin assessment on a patient with ...

[Cooldude101]

The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient?
 
  a. Disposable measuring tape
  b. Cotton-tipped applicator
  c. Sterile gloves
  d. Halogen light

Question 2

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
 
  a. Stage I
  b. Stage II
  c. Stage III
  d. Stage IV

[ghepp]

Answer to Question 1

ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessmentinspectio nand the entire assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items are not the first items used.

Answer to Question 2

ANS: B
This would be a Stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis and dermis. The ulcer presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.