PAEA Surgery End Of Rotation (EOR) Practice Exam

What does an unstageable pressure ulcer consist of?

1. It is always superficial

2. It is covered with dead tissue and the depth cannot be determined

3. It has no associated pain or discomfort

4. It is deep and extends into the subcutaneous layer

The correct answer is: It is covered with dead tissue and the depth cannot be determined

An unstageable pressure ulcer arises when the wound bed is obscured by non-viable tissue, such as slough or eschar. This layer of dead tissue makes it impossible to accurately assess the depth of the ulcer because the base of the wound cannot be seen. In practical terms, this means that the true extent of tissue damage beneath the necrotic tissue is undetermined, which is critical for planning appropriate treatment and management strategies. For instance, if there is significant tissue loss but it is covered by a thick layer of dead tissue, healthcare providers cannot discern how deep the ulcer goes. This distinction is vital because deeper pressure ulcers typically require more intensive management and resources. The other options do not accurately represent the characteristics of an unstageable pressure ulcer. It is not always superficial; it can vary in depth but is simply obscured. Additionally, while many ulcers may not be painful, it is not accurate to generalize that unstageable pressure ulcers have no associated pain. Lastly, an unstageable pressure ulcer cannot be classified as deep in the conventional sense, since 'deep' implies visibility of the wound base where a definitive assessment can be made.