68. A large, red area is noted over a client's right greater trochanter. To differentiate between simple redness and a Stage I decubitus ulcer, a nurse should:
68. A large, red area is noted over a client's right greater trochanter. To differentiate between simple redness and a Stage I decubitus ulcer, a nurse should:
. Note if the redness lasts longer than 30 minutes.
. Press on the intact skin to see if it blanches.
. Look for areas of blistering.
. Check for subcutaneous tissue breakdown.
Test-Taking Tip
The question asks for the sign that may be indicative of stage I ulcer.
Content Area: Adult Health, Integumentary; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
.
Answer 1 is incorrect because the redness of a stage I ulcer does not last, but progresses to a dusky blue-gray color. If it is simple redness, it will resolve in less than 30 minutes. Answer 2 is correct because the redness of a stage I ulcer does not blanch with pressure, whereas simple redness will blanch. Answer 3 is incorrect because blisters are a sign of a stage II pressure ulcer. Answer 4 is incorrect because subcutaneous tissue breakdown occurs with a stage II pressure ulcer.