What is the correct and complete group of descriptions you would use to document a wound?

Choice A reason: Stage 4 pressure injury involves full-thickness tissue loss with exposed muscle, bone, or tendon, as described with a deep depression and visible bone. This severe stage requires aggressive interventions like debridement or surgery. Accurate staging ensures proper wound care, preventing infection and promoting healing in advanced pressure injuries.

Choice B reason: Stage 3 involves full-thickness loss to subcutaneous tissue, not muscle or bone, unlike the described injury with visible bone (stage 4). Misstaging as 3 underestimates severity, risking inadequate treatments like simple dressings, delaying surgical intervention or infection control critical for deep pressure injuries with bone exposure.

Choice C reason: Stage 1 is intact skin with erythema, not a deep lesion with bone exposure, which is stage 4. Misstaging as 1 grossly underestimates severity, neglecting urgent needs like debridement or antibiotics, risking infection, sepsis, or further tissue loss in severe pressure injuries requiring advanced wound management.

Choice D reason: Stage 2 involves partial-thickness loss with a shallow wound, not deep muscle or bone exposure, as in stage 4. Misstaging as 2 risks inadequate care, like topical treatments instead of surgical intervention, delaying healing and increasing complications like osteomyelitis in severe pressure injuries with visible bone.

Choice A reason: Blood pressure 127/65 and HR 68 are within normal ranges (BP <130/<80, HR 60-100), expected in healthy cardiovascular assessments. Trace edema is abnormal, suggesting fluid retention. Assuming this is unexpected risks overlooking normal findings, diverting focus from issues like edema needing evaluation in cardiovascular assessments.

Choice B reason: Trace edema in bilateral lower ankles is an unexpected finding, indicating potential fluid overload, heart failure, or venous insufficiency. Unlike normal vitals or pulses, edema requires investigation and reporting. Recognizing this ensures timely diagnosis and management, critical for preventing progression of underlying cardiovascular or systemic conditions in affected patients.

Choice C reason: Capillary refill within 2 seconds is normal, indicating adequate peripheral perfusion, expected in cardiovascular assessments. Edema is the abnormal finding. Assuming refill is unexpected risks misprioritizing normal findings, neglecting issues like edema that signal potential heart or venous issues, critical for accurate cardiovascular evaluation and care.

Choice D reason: Equal apical and radial pulses are expected, reflecting synchronized cardiac output, normal in cardiovascular assessments. Trace edema is abnormal, suggesting fluid issues. Assuming pulses are unexpected risks overlooking normal findings, diverting attention from edema, critical for identifying and managing underlying cardiovascular conditions in clinical practice.