Difficulty: Medium
Average Score: 86%
Simulated
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?
Correct answer
B
Rationale
The correct answer is B: Skin loss involving up to the subcutaneous tissue (fat). In a stage 3 pressure ulcer, the skin is completely lost, exposing the subcutaneous tissue. This stage indicates significant tissue damage and requires immediate attention to prevent further complications.
A: Reddened intact skin is characteristic of a stage 1 pressure ulcer.
C: Skin loss involving up to the dermis layer is indicative of a stage 2 pressure ulcer.
D: Exposed bone is a manifestation of a stage 4 pressure ulcer, where tissue damage extends to the bone.
A: Reddened intact skin is characteristic of a stage 1 pressure ulcer.
C: Skin loss involving up to the dermis layer is indicative of a stage 2 pressure ulcer.
D: Exposed bone is a manifestation of a stage 4 pressure ulcer, where tissue damage extends to the bone.