Galen college of nursing NUR 155 exam 3 study
set Questions and Answers with Complete
Solution 2025 | 100% Correct
Characteristics of a stage 1 pressure ulcer - ANSWERS A no blanchable area
with redness
Has minor soft tissue swelling and warmth to area
Skin is intact
Normally reversible with appropriate nursing care
Characteristics of a stage 2 pressure ulcer - ANSWERS Partial thickness with
loss of skin including the epidermis and or dermis
Includes superficial wounds like cuts, blisters, or small open areas
Wound is painful
Ulcer is seen with reddish pinkish bed without slough or bruising
It's superficial and can appear as a blister, or shallow crater
,Edema persists
Can become infected with pain and scant drainage
Characteristics of a stage 3 pressure ulcer - ANSWERS Full thickness skin loss
Injury extends through the dermis to the underlying fascia but does not extend
through the underlying fascia
Not always a deep wound depends on location of wound
Wound base is painful
Ulcer appears as a deep crater
Can have tunneling and undermining but not necessary to be considered a stage 3
Drainage and infection are common
Characteristics of a stage 4 pressure ulcer - ANSWERS Has full thickness skin
loss with visible muscle, tendon , and or bone present
Parts may be covered in slough or Eschar
, Not usually painful due to necrosis
Deep pockets of infection may be present
Undermining and tunneling are usually present
Can be destruction , tissue necrosis , or damage to the muscle , tendon , and bone
Unstageable pressure ulcer characteristics - ANSWERS When slough or eschar
interferes with assessment of depth of pressure injury and therefore staging is not
possible
Characteristics of a suspected deep tissue injury - ANSWERS Skin is intact
Patient had a purple or dark red or brown discoloration on the skin
Occurs when a pressure injury occurs underneath the skin so depth is unable to
be determined
Patient may have complained of pain in area before the discoloration occurred
The skin may have felt mushy , warm , or cool compared to surrounding areas of
skin
set Questions and Answers with Complete
Solution 2025 | 100% Correct
Characteristics of a stage 1 pressure ulcer - ANSWERS A no blanchable area
with redness
Has minor soft tissue swelling and warmth to area
Skin is intact
Normally reversible with appropriate nursing care
Characteristics of a stage 2 pressure ulcer - ANSWERS Partial thickness with
loss of skin including the epidermis and or dermis
Includes superficial wounds like cuts, blisters, or small open areas
Wound is painful
Ulcer is seen with reddish pinkish bed without slough or bruising
It's superficial and can appear as a blister, or shallow crater
,Edema persists
Can become infected with pain and scant drainage
Characteristics of a stage 3 pressure ulcer - ANSWERS Full thickness skin loss
Injury extends through the dermis to the underlying fascia but does not extend
through the underlying fascia
Not always a deep wound depends on location of wound
Wound base is painful
Ulcer appears as a deep crater
Can have tunneling and undermining but not necessary to be considered a stage 3
Drainage and infection are common
Characteristics of a stage 4 pressure ulcer - ANSWERS Has full thickness skin
loss with visible muscle, tendon , and or bone present
Parts may be covered in slough or Eschar
, Not usually painful due to necrosis
Deep pockets of infection may be present
Undermining and tunneling are usually present
Can be destruction , tissue necrosis , or damage to the muscle , tendon , and bone
Unstageable pressure ulcer characteristics - ANSWERS When slough or eschar
interferes with assessment of depth of pressure injury and therefore staging is not
possible
Characteristics of a suspected deep tissue injury - ANSWERS Skin is intact
Patient had a purple or dark red or brown discoloration on the skin
Occurs when a pressure injury occurs underneath the skin so depth is unable to
be determined
Patient may have complained of pain in area before the discoloration occurred
The skin may have felt mushy , warm , or cool compared to surrounding areas of
skin
