Pressure Ulcer Staging Quiz with Pictures: Identify Stages

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Questions and Answers

What is the purpose of the E Chart in vision testing?

To test near visual acuity in clients who can read

To test distant visual acuity in clients who can read

To test vision in clients who cannot read or have a verbal communication handicap (correct)

To test vision in clients who wear glasses

How far should the client stand from the vision chart during a vision test?

20 feet (correct)

10 feet

30 feet

40 feet

What does the top number in a vision test result, such as 20/20, represent?

The last full line the client could read

The client's age

The distance from the client to the chart (correct)

The number of letters missed by the client

What should the client do with their glasses during a vision test?

Leave them on, unless they are reading glasses Signup and view all the answers

What should be recorded if the client misses any letters on a line during a vision test?

The number of letters missed, using a minus sign Signup and view all the answers

What is the purpose of the Snellen Chart in vision testing?

To test distant visual acuity Signup and view all the answers

What type of skin lesions arise from normal skin due to irritation or disease?

Primary skin lesions Signup and view all the answers

What may be present on some parts of a pressure ulcer?

Slough or eschar Signup and view all the answers

What is the term for the base of the ulcer being covered by slough and/or eschar in the wound bed?

Unstageable Signup and view all the answers

What is the purpose of inspecting for lesions during a physical assessment of the skin?

To detect abnormalities indicating local or systemic problems Signup and view all the answers

What type of skin lesion can be either primary or secondary?

Skin cancer lesion Signup and view all the answers

What is a characteristic of vascular skin lesions?

They are reddish-bluish in color Signup and view all the answers

What is indicated when the client moves the chart away from the eyes to focus on the print?

Presbyopia Signup and view all the answers

What is the purpose of the near visual acuity procedure?

To evaluate near vision in middle-aged clients Signup and view all the answers

What is evaluated during the confrontation test?

Gross peripheral vision Signup and view all the answers

What does a delayed or absent perception of the examiner’s finger indicate during the confrontation test?

Reduced peripheral vision Signup and view all the answers

What is assessed during the positions test?

Extraocular muscle strength and cranial nerve function Signup and view all the answers

What is the term for an oscillating movement of the eye?

Nystagmus Signup and view all the answers

What can be detected when light directed to the blind eye results in no response in either pupil?

Monocular blindness Signup and view all the answers

What is the purpose of testing accommodation of pupils?

To evaluate convergence of eyes Signup and view all the answers

What may be associated with malaligned or low-set ears?

Down syndrome Signup and view all the answers

What is indicated by tenderness over the mastoid process?

Mastoiditis Signup and view all the answers

What is characterized by foul-smelling, sticky, yellow discharge?

Otitis externa Signup and view all the answers

What can result in conductive hearing loss?

Impacted cerumen Signup and view all the answers

What is the primary purpose of Weber's test?

To determine the type of hearing loss Signup and view all the answers

What is the normal finding in the Rinne test?

Air conduction sound is heard longer than bone conduction sound Signup and view all the answers

In a client with sensorineural hearing loss, what would be reported during Weber's test?

Lateralization of sound to the good ear Signup and view all the answers

What is the purpose of the Romberg test?

To test the client's equilibrium Signup and view all the answers

What is the normal result in the Romberg test?

The client maintains position for 20 seconds without swaying Signup and view all the answers

What is the abnormal finding in the Rinne test for conductive hearing loss?

Bone conduction sound is heard longer than or equally as long as air conduction sound Signup and view all the answers

Study Notes

Pressure Ulcers

May have slough or eschar on some parts of the wound
Can extend into muscle and/or supporting structures
Unstageable: full-thickness tissue loss with base of the ulcer covered by slough and/or eschar

Physical Assessment: Skin

Inspect for lesions, noting color, shape, and size
Primary lesions: arise from normal skin due to irritation or disease
Secondary lesions: arise from changes in primary lesions
Vascular lesions: reddish-bluish, seen with bleeding, venous pressure, aging, liver disease, or pregnancy
Skin cancer lesions: can be primary or secondary, classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma

Physical Assessment: Ears

Inspect the auricle, tragus, and lobule for malaligned or low-set ears (associated with genitourinary disorders or chromosomal defects)
Palpate the auricle and mastoid process for tenderness or auricular cyst
Inspect the external auditory canal for redness, swelling, scaling, or itching (otitis externa), or foul-smelling, sticky, yellow discharge
Inspect the external auditory canal for blood or watery drainage (cerebrospinal fluid) related to skull trauma

Hearing and Equilibrium Tests

Weber's Test: lateralization of sound to the good ear with sensorineural hearing loss
Rinne Test: compares air and bone conduction sounds, with normal findings of air conduction sound heard longer than bone conduction sound
Abnormal findings: conductive hearing loss (bone conduction sound heard longer than or equally as long as air conduction sound) or sensorineural hearing loss (air conduction sound heard longer than bone conduction sound)
Romberg Test: tests equilibrium, with normal findings of client maintaining position for 20 seconds without swaying or with minimal swaying

Physical Assessment: Eyes

Test accommodation of pupils, with normal findings of pupils constricting and eyes converging
External Eye Structure: inspect the eyelids and eyelashes
Vision Charts: used to test distant visual acuity, with Snellen Chart or E Chart
Test Results: documented as distance from the client to the chart over the last full line the client could read, with notation of glasses worn during the test
Near Visual Acuity: test using a hand-held vision chart, with normal findings of N: 14/14 with or without corrective lenses
Evaluating Vision: test visual fields for gross peripheral vision using the confrontation test
Extraocular Muscle Function: perform the positions test to assess eye muscle strength and cranial nerve function, with abnormal findings of failure of eyes to follow movement symmetrically in any or all directions

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Description

Assess your knowledge of pressure ulcer identification, including unstageable ulcers, full-thickness tissue loss, and physical assessment techniques. Learn to inspect for lesions and observe skin surface abnormalities.

Identifying Pressure Ulcer Stages