Certified Wound Care Nurse (CWCN) Practice Exam

What characteristic is indicative of deep tissue pressure injury?

1. Shallow yellow wound bed

2. Intact nonblanchable skin

3. Localized area of purplish discoloration

4. Dry, intact skin

The correct answer is: Localized area of purplish discoloration

The characteristic indicative of a deep tissue pressure injury is a localized area of purplish discoloration. This is significant because it suggests that there is underlying tissue damage, even if the skin appears intact. Deep tissue injuries often present as discolored areas, typically in shades of purple or maroon. This discoloration indicates damage to the deeper layers of the skin and surrounding tissues, which may not be immediately visible on the surface. Identifying deep tissue pressure injuries is crucial for early intervention and prevention of further damage. It is important to understand that while the skin might appear intact on the surface, the purplish discoloration serves as a visual cue that deeper tissue is compromised and potentially at risk for further injury. This knowledge is vital in wound care management, as it directs the clinician to monitor the area closely and implement appropriate preventative measures and treatments.