Which of the following assessment findings is most representative of a

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

ANSWER

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.