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.