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    Ati nurs100 physical assessment proctored exam

    The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

    Explanation & Rationale

    A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case. B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4. C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2. D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.

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