Question

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Answer 1

The pressure ulcer described is categorized as Stage II, involving partial-thickness loss of skin layers.

Step-by-step explanation:

The pressure ulcer described in the question is categorized as Stage II.

Stage II pressure ulcers involve partial-thickness loss of skin layers and may appear as shallow open sores or blisters.

In this case, the nurse observed full-thickness tissue loss with visible subcutaneous fat, which indicates Stage II.