The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.
You would document this wound as:
stage 1.
unstageable.
deep tissue injury.
stage 2.
The Correct Answer is B
Choice A rationale:
A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.
Choice B rationale:
Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Choice C rationale:
Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Choice D rationale:
A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A laceration is a cut or tear in the skin, not a raised scar.
Choice B rationale:
A contusion is a bruise caused by an impact to the skin, not a raised scar.
Choice C rationale:
A keloid is a thick, raised scar that can develop at the site of an injury or inflammation. It’s more common in people with darker skin tones.
Choice D rationale:
A hematoma is a collection of blood outside of the blood vessels, not a raised scar.
Correct Answer is C
Explanation
Choice A rationale:
Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Choice B rationale:
Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.
Choice C rationale:
Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
Choice D rationale:
Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.
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