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    Pharmacology Proctored exam 1

    During the nurse's initial physical assessment of an older client, the nurse notes that the client has a pressure injury on the left hip. The nurse finds eschar covering the base of the wound bed. How would the nurse document the stage of the pressure injury?

    Explanation & Rationale

    A. Stage 2: Stage 2 pressure injuries involve partial-thickness loss of skin with exposure of the dermis. They often appear as a shallow open ulcer with a red or pink wound bed or may present as an intact or ruptured blister. The wound bed must be visible to determine the depth of tissue damage, a wound covered by eschar cannot be classified as stage 2. B. Stage 4: Stage 4 pressure injuries involve full-thickness tissue loss with exposed or directly palpable structures such as muscle, tendon, cartilage, or bone. The wound base must be clearly visible to confirm this depth of damage. When thick eschar covers the wound bed, the actual depth of tissue destruction cannot be determined, making stage 4 classification inappropriate. C. Unstageable: A pressure injury is classified as unstageable when full-thickness tissue loss is suspected but the wound base is obscured by slough or eschar. The presence of thick, dark necrotic tissue prevents visualization of the underlying structures, making accurate staging impossible. The wound can only be staged after the eschar is removed and the true depth of tissue damage becomes visible. D. Stage 1: Stage 1 pressure injuries are characterized by intact skin with non-blanchable erythema, typically appearing as persistent redness over a bony prominence. There is no open wound and no tissue loss at this stage. The presence of eschar covering the wound bed indicates significant tissue necrosis and confirms that the injury is far more advanced than stage 1.

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