Certified Medical-Surgical Registered Nurse Practice Exam

Which of the following is true about a suspected deep tissue injury?

1. It is characterized by full-thickness tissue loss

2. It involves exposure of bone, tendon, or muscle

3. It presents with a purple or maroon localized area of skin

4. It represents a shallow open ulcer

The correct answer is: It presents with a purple or maroon localized area of skin

A suspected deep tissue injury is characterized by a localized area of skin that has a purple or maroon discoloration, indicating that there has been damage to the deeper layers of the tissue. This discoloration suggests that there is possible injury to the underlying soft tissue, often related to pressure or shear forces that disrupt the blood supply. The key aspect of this type of injury is that the skin may still appear intact, but the underlying tissue has sustained significant damage. In contrast, full-thickness tissue loss involves a more extensive injury where the dermis and epidermis have been fully breached, leading to exposure of underlying structures such as muscle or bone. This is not applicable to a suspected deep tissue injury. Similarly, while deep tissue injuries can indicate underlying damage, they do not typically involve exposed bone, tendon, or muscle, which is present in more advanced pressure injuries. Lastly, a shallow open ulcer implies a superficial wound rather than the deeper level of damage indicated by a suspected deep tissue injury. Therefore, the defining characteristic of the suspected deep tissue injury is indeed the presence of a localized purple or maroon area of skin, pointing to deeper soft tissue trauma.