Unexpected findings of the musculoskeletal assessment are all of the following except?

Choice A reason: Full thickness skin loss with visible bone indicates a stage 4 pressure injury, not stage 1, which involves intact skin with erythema. Misidentifying this overstates severity, risking inappropriate interventions like surgical debridement instead of preventive measures like repositioning, critical for managing early-stage pressure injuries to prevent progression.

Choice B reason: Stage 1 pressure injury presents as intact skin with non-blanchable localized erythema, often over bony prominences, due to early tissue compression. This finding guides preventive care, like pressure relief and skin protection, to halt progression. Accurate identification ensures timely interventions, reducing risk of deeper tissue damage in at-risk patients.

Choice C reason: Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury, not stage 1, which has intact skin. Assuming this misdiagnoses severity, leading to unnecessary aggressive treatments like wound dressings, while neglecting early interventions like offloading pressure, critical for preventing worsening of stage 1 injuries.

Choice D reason: Partial-thickness skin loss with red tissue indicates a stage 2 pressure injury, not stage 1, which shows intact skin with erythema. Misidentifying this risks inappropriate wound care, delaying preventive strategies like skin moisturizing or repositioning, essential for managing stage 1 injuries and preventing progression to deeper ulcers.

Choice A reason: The left lower quadrant contains the sigmoid colon and parts of the small intestine, not the liver. Liver assessment involves palpation and percussion in the right upper quadrant, where it resides, making this choice incorrect for locating the liver anatomically.

Choice B reason: The liver is located in the right upper quadrant, beneath the diaphragm, extending slightly into the left upper quadrant. It is assessed via percussion and palpation in the RUQ to evaluate size or tenderness, making this the correct choice for liver localization.

Choice C reason: The left upper quadrant houses the stomach, spleen, and parts of the pancreas, not the liver’s primary location. While the liver’s left lobe extends slightly into the LUQ, its main mass is in the RUQ, making this choice incorrect.

Choice D reason: The right lower quadrant contains the appendix and cecum, not the liver. Liver assessment targets the right upper quadrant, where its bulk resides, making this choice incorrect for identifying the liver’s anatomical position during physical examination.