NCLEX Question for stage of pressure ulcer development

NCLEX Review Question

During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone?

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

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

Stage III
Rationale: A stage III ulcer extends into the subcutaneous tissue.

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