The nurse is caring for a client who has an ulceration appearing as a deep crater with undermining of adjacent tissue loss. The nurse recognizes that this client has which type of ulcer present?

Question

a. stage I c. stage III
b. stage II d. stage IV

Answer 1

C
The degree of tissue damage in pressure ulcers has been classified into four stages. In stage I pressure ulcers, skin is intact and nonblanchable erythema is present. In stage II, a superficial ulcer (abrasion, blister, or shallow crater) is present and there is partial-thickness skin loss. In stage III, a deep crater with or without undermining of adjacent tissue loss is present and there is full-thickness skin loss. In stage IV, there is extensive destruction; tissue necrosis; damage to muscle, bone, or supporting structures; and full-thickness skin loss.