The nurse is performing a skin assessment on a client that is admitted to the hospital and observes an area over the left heel that is reddened but intact. How would the nurse stage this pressure sore?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
A
Feedback:
Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage II is the same as stage I but has a blister or shallow break in the skin. Stage III has superficial skin impairment that progress to a shallow crater that extends to the subcutaneous tissue. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.
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