Author Question: A patient is being seen in the Emergency Department for a puncture wound on the foot. The patient ... (Read 111 times)

sdfghj · **on:** Jul 22, 2018

A patient is being seen in the Emergency Department for a puncture wound on the foot. The patient was walking in a construction site, but is unsure what caused the injury.

During the initial assessment the nurse determines if the patient has received a tetanus toxoid injection within which time frame? a. Within the past year
b. Within the last 3 years
c. Within the last 5 years
d. Within the last 10 years

Question 2

A middle-age adult paraplegic patient has been admitted for follow-up from a traumatic brain injury received while serving in Afghanistan. The admitting diagnosis is failure-to-thrive.

On admission, the patient was found to have a wound on the right scapula. The nurse noted full-thickness tissue loss with tunneling, but did not note any bone, tendon, or muscle. This was correctly identified as what stage of a pressure ulcer? a. Stage I
b. Stage II
c. Stage III
d. Stage IV

SamMuagrove · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
When an injury results from trauma from a dirty penetrating object, determine if the patient has received a tetanus toxoid injection within the last 10 years. Within the past year, 3 years, or 5 years is too early.

Answer to Question 2

C
Stage 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
Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister
Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling