Which of the following assessment findings is most representative of a stage II pressure ulcer?
1. A blister
2. Undermining
3. Nonblanchable redness
4. Visible subcutaneous fat
ANS: 1
Stage II ulcers have partial-thickness skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. The remaining op-tions describe elements of stage I and stage III ulcers.
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