Pressure Ulcer Staging Quiz
Questions: 16 · 10 minutes
1. Which statement about the progression of a deep tissue pressure injury is accurate?
It may evolve rapidly and reveal deeper tissue damage despite appropriate care
It must remain intact to retain its classification
It always develops through Stages 1 and 2 before becoming deeper
It is defined by visible adipose tissue in a shallow wound
2. A pressure-related wound contains exposed bone at its base. What is the appropriate stage?
Stage 4 pressure injury
Stage 3 pressure injury
Unstageable pressure injury
Stage 2 pressure injury
3. Pressure damage is found on the mucous membrane inside the nostril where an oxygen device rests. How should the injury be handled within the standard staging system?
Stage it according to its measured depth
Automatically classify it as Stage 2
Classify it as unstageable until the device is removed
Identify it as a mucosal membrane pressure injury without assigning a numbered stage
4. A documented Stage 4 pressure injury is healing and now appears shallower. How should its history generally be recorded?
Reverse-stage it to Stage 3 as depth decreases
Remove the stage once granulation tissue appears
Relabel it unstageable until healing is complete
Describe it as a healing Stage 4 pressure injury rather than reverse-staging it
5. A heel has dry, adherent, intact eschar without redness, drainage, or fluctuance. What is the most appropriate general approach?
Remove the eschar immediately so a stage can be assigned
Classify it as Stage 4 because it is on the heel
Leave the stable eschar intact, offload the heel, and monitor clinically
Classify it as Stage 2 because the eschar appears superficial
6. A patient has a shallow, open sacral wound with a moist pink-red bed. The dermis is exposed, but adipose tissue and deeper structures are not visible. How should it be staged?
Stage 1 pressure injury
Stage 2 pressure injury
Stage 3 pressure injury
Unstageable pressure injury
7. How does anatomical location affect the appearance of a Stage 3 pressure injury?
Depth can vary by location, and undermining or tunneling may occur
Stage 3 injuries have the same depth at every body site
Stage 3 can be assigned only where adipose tissue is absent
Any deep wound over the heel must be Stage 4
8. Which finding defines a Stage 1 pressure injury?
Full-thickness skin loss with visible adipose tissue
Partial-thickness skin loss with exposed dermis
Intact skin with localized, non-blanchable erythema
Intact skin with a purple or maroon area indicating deep tissue damage
9. Intact skin over a bony prominence shows persistent, non-blanchable deep red and maroon discoloration after prolonged pressure. Which classification is most appropriate?
Stage 1 pressure injury
Deep tissue pressure injury
Stage 2 pressure injury
Unstageable pressure injury
10. A patient with frequent incontinence has diffuse, irregular superficial erosion across the buttocks rather than a localized injury over a pressure point. What is the most appropriate interpretation?
Consider moisture-associated skin damage rather than automatically calling it Stage 2
Classify it as Stage 1 because the buttocks are discolored
Classify it as deep tissue pressure injury because moisture weakens tissue
Classify any shallow open area on the buttocks as Stage 2
11. The base of a pressure injury is completely covered by slough and eschar, so the depth of tissue loss cannot be confirmed. How is it classified?
Stage 3 pressure injury
Stage 2 pressure injury
Unstageable pressure injury
Deep tissue pressure injury
12. A wound has full-thickness skin and tissue loss, but thick slough prevents the clinician from seeing whether muscle, tendon, or bone is exposed. What should be documented?
Stage 3 because full-thickness loss is visible
Stage 4 because deep structures might be involved
Deep tissue pressure injury because discoloration may be hidden
Unstageable pressure injury because the full extent is obscured
13. A relatively small pressure-related opening reveals exposed tendon. Which feature determines its stage?
The small surface area makes it Stage 2
Exposed tendon makes it Stage 4
Its apparent shallowness makes it Stage 3
Its size makes it unstageable
14. A localized skin pressure injury matches the shape of a medical device. It is not on a mucous membrane. How should it generally be classified?
Record only the device name because device-related injuries are not staged
Use the standard staging system and identify the device-related cause
Classify every device-related injury as deep tissue pressure injury
Call it unstageable until the device is permanently discontinued
15. A wound has full-thickness skin loss with visible adipose tissue and granulation tissue. Fascia, muscle, tendon, cartilage, and bone are not exposed. Which stage best fits?
Stage 2 pressure injury
Deep tissue pressure injury
Stage 3 pressure injury
Stage 4 pressure injury
16. During a skin check, an intact pink area over a pressure point becomes pale when pressed and promptly returns to its prior color. What does this finding indicate about Stage 1 criteria?
It confirms Stage 1 because any intact redness qualifies
It confirms deep tissue pressure injury because the skin is intact
It should be classified as Stage 2 because pressure changed the color
It does not currently meet the non-blanchable erythema criterion for Stage 1, though prevention and reassessment may still be appropriate