The Nurse Assesses an Open Area Over a Client's Greater

question 25

Multiple Choice

The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is oedematous and feels boggy. The edges of the wound cup in toward the centre. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?

• A) The joint capsule of the hip is visible.
• B) The ulcer has thick dark eschar over the top.
• C) The crater extends into the subcutaneous tissue
• D) There is undermining of adjacent tissues.

---

Definitions:

Self-conscious Emotions

Emotions that require self-awareness and reflection, such as embarrassment, pride, shame, and guilt, often developing in the context of social interactions.

Social Smile

A smile that is socially motivated, typically in response to another person, used as a basic act of social communication.

Cognitive Competence

The ability to think logically, make decisions, solve problems, and adapt to new situations.

Social Referencing

The process of reading emotional cues in others to help determine how to act in a particular situation, often observed in infants looking to caregivers.