Asked by Brianna Edwards on Jul 05, 2024
Verified
The patient has a nonblanchable area of redness on the right malleolus.Which pressure injury stage will be recorded in the patient's chart?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Nonblanchable
Describing skin redness that does not turn white (blanch) when pressed, often indicating pressure injury.
Right Malleolus
The bony protrusion on the outside of the right ankle, part of the fibula bone.
- Accurately recognize and record the phases of pressure wounds.
Verified Answer
TS
tannu sidhuJul 10, 2024
Final Answer :
A
Explanation :
Stage 1: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage 2: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage 3: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage 4: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling
Stage 2: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage 3: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage 4: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling
Learning Objectives
- Accurately recognize and record the phases of pressure wounds.
Related questions
The Nurse Is Caring for a Patient with a Stage ...
The Nurse Is Caring for a Patient with a Stage ...
Which Factor Contributes to Pressure Injury Formation When Patient's Body ...
The Nurse Is Working on a Medical-Surgical Unit That Has ...
Which Nursing Observation Would Indicate That the Patient Was at ...