Wound, Ostomy and Continence Nurses Society (WOCN) Practice Exam

Which statement best describes a stage 4 pressure injury?

1. Visible underlying adipose tissue

2. Full-thickness skin and tissue loss with exposed structures

3. Localized redness on intact skin

4. Non-blanchable erythema with epidermal damage

The correct answer is: Full-thickness skin and tissue loss with exposed structures

A stage 4 pressure injury is characterized by full-thickness skin and tissue loss, which means that not only is the skin compromised, but also the underlying tissues are involved. This stage can reveal exposed bone, tendon, or muscle structures, making it crucial for clinicians to recognize the extent of tissue damage. In distinguishing pressure injuries, stage 4 is the most severe, showing significant depth, and is notable for the absence of underlying tissues, which can result in serious complications such as infection. Therefore, the description of full-thickness skin and tissue loss with exposed structures accurately reflects the nature of a stage 4 pressure injury and helps guide appropriate interventions and treatment plans. In contrast, the other options describe either less severe forms of tissue damage or specific characteristics associated with earlier stages of pressure injuries, such as localized redness or non-blanchable erythema, which are indicative of stage 1 or stage 2 injuries. Understanding the definitions of each stage according to the classifications set by wound care organizations is vital for accurate patient assessment and effective management of pressure injuries.