A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?a. Stage Ib. Stage IIc. Stage III d. Unstageable

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1. A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?

a. Stage I

b. Stage II

c. Stage III

d. Unstageable

D!

A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.
A, B, C, & E!

Determining the client's perception of the problem is an appropriate question that allows culturally factors to be included. Encouraging the client to discuss her problems will facilitate a clearer understanding of the factors involved. Religion often plays a significant role in a client's view of health, wellness, and recovery. Knowing whether a client has ever undergone treatment for a mental health problem reveals mental health history and how previous issues were addressed. Insurance coverage is not pertinent to the issue and is an inappropriate topic of questioning by the nurse.
B!

These adaptations, as well as anemia, irritability, pruritus, and an enlarged spleen, occur with vitamin A toxicity. Excess thiamine is excreted in the urine and rarely, if ever, causes toxicity; an excessive dose may elicit an allergic reaction in some individuals. Excess vitamin C (ascorbic acid) does not cause these adaptations or toxicity; however, vitamin C may cause diarrhea or renal calculi. Pyridoxine (vitamin B6) is relatively nontoxic, and excess amounts are excreted in the urine.
B!

Eating various foods within recommended exchange units is correct. Exchange lists allow clients to select preferred foods that are acceptable within the prescribed dietary plan. The client who believes that eating anything as long as enough insulin is taken does not fully understand the diabetic teaching. Clients should adhere to a prescribed dietary plan. The client should not take regular insulin at night on an empty stomach but should have a snack before going to bed to prevent nighttime episodes of hypoglycemia. The client should eat a preset balanced breakfast, not a very small one, because it is calculated into the entire plan to balance nutrition, insulin, and exercise.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?a. Stage Ib. Stage IIc. Stage III d. Unstageable

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A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?a. Stage Ib. Stage IIc. Stage III d. Unstageable

❤ If you liked Fatskills, consider supporting us by checking out The Life Manuals You Never Got.

About | Explore | User Guide | Topics | Subjects | Doubt Solver | Career Aptitude Test | Answers | Free Tools | What Should We Know? Privacy | Terms |

Without work one finishes nothing. - Ralph Waldo Emerson© 2026 Fatskills.com

All trademarks, logos and brand names are the property of their respective owners. All company, product and service names used in this website are for identification purposes only. Use of these names, trademarks and brands does not imply endorsement.

About | Explore | User Guide | Topics | Subjects | Doubt Solver | Career Aptitude Test | Answers | Free Tools | What Should We Know?
Privacy | Terms |

Without work one finishes nothing. - Ralph Waldo Emerson
© 2026 Fatskills.com