In a patient with a stage II pressure ulcer,the nurse describes the wound as:

A) superficial blistering.
B) nonblanchable redness.
C) loss of skin without bone exposure.
D) loss of skin with exposed muscle.

Question

Teresa Cummins · Accepted Answer

Final Answer : A, Explanation :  A stage II pressure ulcer is defined by partial-thickness loss presenting as a shallow open ulcer with a red to pink wound bed,without slough.It also may present as an intact or open/ruptured serum-filled blister.It usually presents as a shiny or dry shallow ulcer without sloughing or bruising.The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area,usually over a bony prominence.The area may be painful,firm,soft,and warmer or cooler as compared with adjacent tissue.Stage III pressure ulcers involve full-thickness skin loss.Subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed.Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone,tendon,or muscle.Slough or eschar may be present in some parts of the wound bed.

In a patient with a stage II pressure ulcer,the nurse describes the wound as:

A) superficial blistering.
B) nonblanchable redness.
C) loss of skin without bone exposure.
D) loss of skin with exposed muscle.

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Learning Objectives

Related questions

In a patient with a stage II pressure ulcer,the nurse describes the wound as:A) superficial blistering.B) nonblanchable redness.C) loss of skin without bone exposure.D) loss of skin with exposed muscle.

Definitions

Learning Objectives

Learning Objectives

Related questions

In a patient with a stage II pressure ulcer,the nurse describes the wound as:

A) superficial blistering.
B) nonblanchable redness.
C) loss of skin without bone exposure.
D) loss of skin with exposed muscle.