Physiological AdaptationQuestion 382 of 2368

A client has a sacral pressure injury with full-thickness tissue loss and visible muscle at the wound base. Which stage should the nurse document?

  1. Stage 2
  2. Stage 3
  3. Unstageable
  4. Stage 4
Show answer

Correct answer: Stage 4

Stage 4 injuries have full-thickness loss with exposed cartilage, tendon, ligament, muscle, or bone. Stage 3 shows fat but not muscle or bone.

Source: Nursing Skills, 2nd edition (Open RN, Chippewa Valley Technical College, 2023), Wound Care: STAGING. Licensed under CC BY 4.0.

Practice the topic "Physiological Adaptation"

Questions last reviewed: 18 October 2026