The evening nurse reviews the nursing documentation in the male client’s chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area?
A. Intact skin
B. Full-thickness skin loss
C. Exposed bone, tendon, or muscle
D. Partial-thickness skin loss of the dermis
Correct Answer: D. Partial-thickness skin loss of the dermis
In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without a slough. It may also present as an intact, open, or ruptured, serum-filled blister.
Option A: The skin is intact in stage I.
Option B: Full-thickness skin loss occurs in stage 3.
Option C: Exposed bone, tendon, or muscle is present in stage 4.
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