GERI FINAL EXAM WITH 100% CORRECT SOLUTIONS 2024

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? A. Crusting B. Wrinkling C. Deepening of expression lines D. Thinning and loss of elasticity in the skin correct answersA. Crusting Wrinkling, deepening of expression lines, and thinning and loss of elasticity in the skin are are considered normal changes of aging. Crusting is concerning for a pathological condition. A patient's documentation indicates he has a stage III pressure ulcer on his right hip. What should the nurse expect to find on assessment of the patient's right hip? A. Exposed bone, tendon, or muscle B. An abrasion, blister, or shallow crater C. Deep crater through subcutaneous tissue to fascia D. Persistent redness (or bluish color in darker skin tones) correct answersC. Deep crater through subcutaneous tissue to fascia A stage III pressure injury involves full thickness skin loss or necrosis of the subcutaneous tissue that may extend down to but not through the underlying fascia A. Stage IV B. Stage II C. Stage III D. Stage I Which patient is at the greatest risk for developing pressure ulcers? A. A 42-year old obese woman with type 2 diabetes B. A 78-year old man who is confused and malnourished C. An 80-year old man who is comatose following a head injury D. A 65-year old woman who has urge and stress incontinence correct answersC. An 80-year old man who is comatose following a head injury Although diabetes, malnutrition, and incontinence can increase risk of pressure injuries, an elderly patient, immobilized in an intensive care unit is at the highest risk. The patient is transferring from another facility with the description of a sore on her sacrum that is deep enough to see the muscle. What stage of pressure ulcers does the nurse expect to see on admission? A. Stage I B. Stage II