Physical Therapy Assistant Practice Exam

What may be a visible characteristic of ulcers classified as unstageable?

1. Deep tissue injury

2. Exposed muscle

3. Slough or eschar covering the base

4. Full-thickness tissue loss with visible adipose tissue

The correct answer is: Slough or eschar covering the base

Unstageable ulcers are characterized by the presence of slough or eschar covering the wound bed, which prevents assessment of the extent of tissue damage. This means that the full depth of the ulcer cannot be determined because necrotic tissue obstructs a clear view of the underlying structures. When slough or eschar is present, it can be yellow, tan, gray, green, or brown and is composed of dead cells, bacteria, and inflammatory exudate. It indicates that local tissue injury has occurred, but the definitive staging cannot be established without first removing this necrotic tissue to expose the wound bed. In contrast, the other options refer to specific types of tissue injuries or characteristics that allow for clear staging. For instance, deep tissue injury signifies damage that can be felt but is not immediately visible, exposed muscle indicates that the ulcer has reached deeper layers of tissue, and full-thickness tissue loss suggests a degree of damage that is clearly observable. What sets unstageable ulcers apart is the obscured view caused by slough or eschar, reinforcing why this characteristic is central to their classification.