Author Question: A nurse assesses a pressure ulcer on a child and finds full-thickness loss of the dermal layer and ... (Read 64 times)

lb_gilbert · **on:** Jun 28, 2018

A nurse assesses a pressure ulcer on a child and finds full-thickness loss of the dermal layer and visible subcutaneous fat. At which stage does the nurse document this pressure ulcer to be?

A.
Stage I
B.
Stage II
C.
Stage III
D.
Stage IV

Question 2

A nurse is caring for four patients on a general pediatric unit. The nurse identifies risk for impaired skin integrity as a nursing diagnosis for all four. Which patient's skin should the nurse assess first?

A.
Adolescent 4 hours postoperative after appendectomy
B.
School-age child just back from a tonsillectomy
C.
Teen eating in a chair 1 week post-burn
D.
Toddler with broken femur in skeletal traction

ApricotDream · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: C
A stage III pressure ulcer involves the full thickness of the dermis, possible visible subcutaneous fat, possible sloughing, and possible tunneling. This is a stage III ulcer.

Answer to Question 2

ANS: D
Immobility is a major risk factor for impaired skin integrity. The nurse should first assess the child in traction, as this child is the least mobile. A child sitting in a chair to eat is at least partially mobile. Children after routine surgery are expected to recover quickly and begin activity within a day.