Question

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected?

A) Full-thickness skin loss
B) Skin pallor
C) Blister formation
D) Eschar formation

Answer 1

In a stage IV pressure ulcer, a nurse would expect to see full-thickness skin loss and possibly signs of eschar formation, which is characteristic of this severe level of tissue injury.

Step-by-step explanation:

A nurse assessing a client with a stage IV pressure ulcer would expect to find full-thickness skin loss with exposed bone, tendon, or muscle. Stage IV pressure ulcers can include slough or eschar formation on some parts of the wound bed. Often these ulcers are so deep that there is damage to deeper tissues, which could lead to infection and require significant medical intervention.

Unlike blisters or pallor, which are indicative of less severe skin damage, a stage IV pressure ulcer represents the most severe form of skin and tissue injury. The correct answer to the question is D) Eschar formation, as this is a common characteristic of severe pressure ulcers where dead tissue that is dry and black in color accumulates in the ulcer.