Nurse Aide NNAAP Exam Prep

Category - Nurse Aide

The first stage of pressure ulcer formation is:

  1. A non blan chable, erythematic area of intact skin
  2. Partial thickness skin loss involving epidermis and/or dermis
  3. Full thickness skin loss involving damage or necrosis of subcutaneous tissue
  4. Full thickness skin loss, tissue necrosis or damage to muscle
Explanation

Answer: A -The first stage of pressure ulcer formation is a non blanch able, erythematic area of intact skin. The stages of pressure ulcer formation are as follows:

  • STAGE 1: The skin is red. The color does not return to normal when the skin is relieved of pressure. The skin is intact.
  • STAGE 2: The skin cracks, blisters, or peels. There may be a shallow crater.
  • STAGE 3: The skin is gone. Underlying tissues are exposed. The exposed tissue is damaged. There may be drainage from the area.
  • STAGE 4: Muscle and bone are exposed and damaged. Drainage is likely.
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