The nurse notes a client's skin is reddened with a small abrasion ...

[Awilson837]

The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as:
 
  1. Stage I
  2. Stage II
  3. Stage III
  4. Stage IV

Question 2

Pressure ulcers form primarily as a result of:
 
  1. Nitrogen buildup in the underlying tissues
  2. Prolonged illness or disease
  3. Tissue ischemia
  4. Poor nutrition

[medine]

Answer to Question 1

ANS: 2
This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and pre-sents clinically as an abrasion, blister, or shallow crater. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Answer to Question 2

ANS: 3
Pressure is the major cause of pressure ulcer formation. Prolonged, intense pressure affects cellu-lar metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ulti-mately tissue death. Prolonged illness or disease and poor nutrition may place a client at risk for pressure ulcer development.