The patient has a large red, blistered area on the left hip.
Which pressure injury stage will be recorded in the patient’s chart?
Stage 2
Stage 4
Stage 3
Stage 1
The Correct Answer is A
Choice A rationale:
Stage 2 pressure injuries are characterized by partial-thickness loss of skin layers involving the epidermis and/or dermis. They present as a red, blistered area, often with an intact or ruptured serum-filled blister. The wound bed is typically moist and may be painful. There is no exposure of underlying bone, tendon, or muscle.
Key features of Stage 2 pressure injuries that align with the patient's presentation:
Red, blistered area: This is a hallmark sign of Stage 2, indicating tissue damage and inflammation in the epidermis and dermis. Large size: The size of the wound suggests more extensive tissue damage, consistent with Stage 2 rather than Stage 1.
Absence of deeper tissue involvement: The absence of exposed bone, tendon, or muscle rules out Stage 3 or 4 pressure injuries.
Rationales for other choices:
Choice B: Stage 4
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. This is not consistent with the patient's presentation, which does not describe exposed deeper tissues.
Choice C: Stage 3
Stage 3 pressure injuries involve full-thickness tissue loss, but without exposed bone, tendon, or muscle. They often present with a deep crater-like appearance and may have undermining or tunneling. The patient's wound does not exhibit these features, making Stage 3 less likely.
Choice D: Stage 1
Stage 1 pressure injuries are characterized by intact skin with non-blanchable redness over a bony prominence. They do not involve blisters or open wounds. The patient's presentation clearly exceeds the features of Stage 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Correct Answer is B
Explanation
Choice A rationale:
Secondary erythema refers to redness that develops after the initial injury or insult. It's not the most accurate term to describe an area that doesn't blanch, as blanching specifically assesses for the presence of blood in the tissue. Secondary erythema can be blanchable or nonblanchable, depending on the underlying cause.
Choice C rationale:
Blanchable hyperemia is a reddening of the skin that blanches (turns lighter) when pressed. This indicates that blood is still flowing to the area and that the tissue is not damaged. It's not the correct term for an area that doesn't blanch.
Choice D rationale:
Reactive hyperemia is a temporary increase in blood flow to an area that has been deprived of blood flow. It's often seen after pressure is relieved from a body part. While reactive hyperemia can cause redness, this redness typically blanches when pressed.
Choice B rationale:
Nonblanchable erythema is the most accurate term to describe an area of redness that does not turn lighter in color when pressed with a finger. This indicates that blood is not flowing to the area and that the tissue is likely damaged. Nonblanchable erythema is a significant finding because it can be a sign of a pressure injury (also known as a bedsore or pressure ulcer).
Key points about nonblanchable erythema:
It's a sign of impaired blood flow to the tissue. It's a potential indicator of a pressure injury.
It requires prompt assessment and intervention to prevent further tissue damage.
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