Which of the following statements made by the nurse shows the most tho

Which of the following statements made by the nurse shows the most thorough understanding of the therapeutic value of testing a reddened area on the heel of a mobility-impaired client for blanching?

1. “If it blanches, the problem isn’t too bad.”
2. “When it stays red, the damage is great.”
3. “Nonblanching hyperemia is a poor indictor of healing.”
4. “Blanching denotes an attempt to deliver blood to the site.”

ANSWER

ANS: 4
If the area blanches (turns lighter in color) and the erythema returns when you remove your fin-ger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanching hyperemia. If, however, the erythemic area does not blanch (nonblanching erythema) when you apply pressure, deep tissue damage is probable.