Asked by Aleksie Dominguez on May 27, 2024

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A middle-age adult paraplegic patient has been admitted for follow-up from a traumatic brain injury received while serving in Afghanistan.The admitting diagnosis is failure-to-thrive.On admission,the patient was found to have a wound on the right scapula.The nurse noted full-thickness tissue loss with tunneling,but did not note any bone,tendon,or muscle.This was correctly identified as what stage of a pressure ulcer?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Full-Thickness Tissue

Tissue damage extending through the entire depth of the skin, often requiring medical intervention for healing.

Traumatic Brain Injury

Physical damage to the brain tissue caused by an external mechanical force, potentially leading to temporary or permanent impairment of cognitive, physical, and psychosocial functions.

Tunneling

A process whereby communications are sent from one network to another in encapsulated form, usually to provide secure passage through an untrusted network.

  • Accurately discern and sort the stages of pressure ulcers.
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RB
Richard BaileyMay 30, 2024
Final Answer :
C
Explanation :
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage I: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage IV: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling