Holistic Nursing Exam 2 Practice

Which statement best describes Stage 4 pressure injury?

Partial thickness skin loss with only the epidermis damaged. Wound base is covered by slough or eschar and extent cannot be determined. Bone, muscle, or tendon is visible; slough or eschar may be present. No tissue loss; only redness.

Correct Answer:

Bone, muscle, or tendon is visible; slough or eschar may be present.

Explanation:

Stage 4 injuries are full-thickness tissue losses with exposure of bone, tendon, or muscle. The wound bed may also contain slough or eschar, and there can be undermining or tunneling. The defining feature is that deeper structures are visible, which sets this stage apart from stages where only skin or subcutaneous tissue loss is present. The statement describing exposure of bone, muscle, or tendon, with possible slough or eschar, matches this deepest level of tissue destruction. This depth confirms full-thickness involvement, rather than a shallower loss or an unstageable wound where depth isn’t assessable due to coverings.

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