NCLEX Question for pressure ulcer development

NCLEX Review Question

During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

a.Stage III
b.Stage IV
c.Stage II
d.Stage I

Correct Answer: A
Stage III
Rationale: Clinically, a deep crater with or without undermining of adjacent tissues is noted.

Stage IV
Rationale: A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone.

Stage II
Rationale: A stage II ulcer exhibits a break in the skin through the epidermis or dermis.

Stage I
Rationale: A stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort.

Posted in: MSN NCLEX