2024 PN NCLEX Questions Nursing Practice Question
A patient has suffered a left CVA and has developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema and the skin is intact. The nurse should score the patient as having which of the following?
Correct Answer: A
Rationale: In this scenario, the presence of non-blanchable erythema over the left elbow indicates a Stage I pressure ulcer. This stage is characterized by intact skin with localized redness that does not fade when pressure is applied, signifying early tissue damage.
Stage II pressure ulcers involve partial thickness loss of skin, presenting as a blister or shallow sore, which is not applicable here since the skin is intact. Stage III pressure ulcers feature full thickness loss with visible fat, and Stage IV includes extensive damage involving muscle or bone, neither of which is evident in this case. Thus, the assessment aligns with a Stage I classification.