A nurse assesses a stage II pressure ulcer as:
A. Superficial blistering
B. Boggy tissue consistency
C. Loss of skin to the underlying fascia
D. Persistent redness or skin darkening
A
A. A stage II pressure ulcer involves the epidermis and/or the dermis and presents as an abrasion, blister, or shallow crater.
B. Boggy tissue consistency indicates a stage I ulcer.
C. Loss of skin to the underlying fascia indicates a stage III ulcer.
D. Persistent redness or skin darkening indicates a stage I pressure ulcer.
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