Wounds and Pressure Ulcers
Wounds and Pressure Ulcers ( 15 Questions)
A client with a pressure ulcer reports partial-thickness skin loss involving the epidermis and/or dermis.
Which symptom should the nurse expect to find during the assessment?
Coldness to the touch is not a characteristic symptom of partial-thickness skin loss involving the epidermis and/or dermis.
This symptom is more indicative of compromised blood flow, such as in arterial insufficiency, and is not specific to pressure ulcers.
Redness around the wound is a characteristic symptom of partial-thickness skin loss (stage 2 pressure ulcer).
This redness is due to localized inflammation and represents damage to the epidermis and/or dermis, but it does not involve muscle or deeper tissues.
Tenderness when touching the wound is an expected symptom in partial-thickness skin loss involving the epidermis and/or dermis (stage 2 pressure ulcer).
The presence of tenderness is indicative of ongoing tissue damage and inflammation in the affected area.
The statement, "My wound is deep, down to the muscle," suggests a full-thickness wound (stage 3 or 4 pressure ulcer) where muscle and deeper tissues are involved.
This statement does not align with the description provided in the question, which specifies partial-thickness skin loss.
Choice A rationale:
Coldness to the touch is not a characteristic symptom of partial-thickness skin loss involving the epidermis and/or dermis.
This symptom is more indicative of compromised blood flow, such as in arterial insufficiency, and is not specific to pressure ulcers.
Choice B rationale:
Redness around the wound is a characteristic symptom of partial-thickness skin loss (stage 2 pressure ulcer).
This redness is due to localized inflammation and represents damage to the epidermis and/or dermis, but it does not involve muscle or deeper tissues.
Choice C rationale:
Tenderness when touching the wound is an expected symptom in partial-thickness skin loss involving the epidermis and/or dermis (stage 2 pressure ulcer).
The presence of tenderness is indicative of ongoing tissue damage and inflammation in the affected area.
Choice D rationale:
The statement, "My wound is deep, down to the muscle," suggests a full-thickness wound (stage 3 or 4 pressure ulcer) where muscle and deeper tissues are involved.
This statement does not align with the description provided in the question, which specifies partial-thickness skin loss.