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A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the
hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a
ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's
skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with
damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of
this pressure ulcer?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4 - Ans ✅ C) Stage 3
A crater appears in the skin, with full-thickness skin loss and damage to or necrosis of
subcutaneous tissue that may extend to, but not through underlying muscle.
Mrs. Anderson presents with an itchy rash which is raised and appears and disappears in various
locations. Each lesion lasts for many minutes. What most likely accounts for this rash?
A) Insect bites
B) Wheals, urticaria, or hives
C) Psoriasis
D) Purpura - Ans ✅ B) Wheals, urticaria, or hives
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