A nurse is assessing a client with a skin condition. Which of the following describes the client’s condition?

Full thickness skin loss with visible bone.

Intact skin with localized erythema.

Partial-thickness skin loss with red tissue.

Full thickness skin loss with visible adipose tissue.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.

Choice B rationale

Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice C rationale

Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale

Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

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Correct Answer is A

Explanation

Choice A rationale

A purplish-colored stoma may indicate compromised circulation, which is a serious condition that requires immediate medical attention18.

Choice B rationale

A rosebud-like stoma orifice is a normal finding and does not need to be reported18.

Choice C rationale

A stoma oozing red drainage is a normal finding immediately after surgery and does not need to be reported18.

Choice D rationale

A shiny, moist stoma is a normal finding and does not need to be reported18.

A. Purulent. B. Sanguineous. C. Serosanguineous. D. Serous.

Correct Answer is C

Explanation

Choice A rationale

Purulent drainage is thick and opaque. It can have a yellow, tan, green, or brown color and is a sign of infection.

Choice B rationale

Sanguineous drainage is bright red and indicates active bleeding3.

Choice C rationale

Serosanguineous drainage is typically pink-red and thin. It is made up of blood and serous fluid and is typically seen in a normal, non-infected wound3.

Choice D rationale

Serous drainage is clear and thin, like the fluid from a blister3.

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