Question

A wound has full-thickness loss muscle-tendon-bone exposed, slough is present, and it has undermining tunneling. What stage is the wound?

1) Stage V
2) Unstageable
3) Stage IV
4) Stage III

Answer 1

The described wound with full-thickness loss and exposed structures corresponds to a Stage IV pressure ulcer, as full depth and critical structures are exposed with presence of slough and undermining.The right answer is option 3

Step-by-step explanation:

The description of a wound with full-thickness loss, exposure of muscle, tendon, and bone, presence of slough, and features such as undermining and tunneling is consistent with a Stage IV pressure ulcer. According to the National Pressure Ulcer Advisory Panel (NPUAP), a Stage IV pressure ulcer is characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Undermining and tunneling often occur in such wounds. A wound cannot be staged as Stage V, as there is no such stage within the NPUAP staging system, and it is not unstageable since the depth of tissue loss is clearly visible.