Difficulty: Medium
Average Score: 90%
Simulated
A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
Correct answer
C
Rationale
The correct answer is C: Partial-thickness skin loss with red tissue in wound bed. In a stage 2 pressure injury, there is partial-thickness skin loss involving the epidermis and possibly part of the dermis, resulting in a shallow open wound with a red-pink wound bed. This stage is characterized by intact or ruptured blister formation. Choice A is incorrect because intact skin with localized erythema is more indicative of a stage 1 pressure injury. Choice B is incorrect as it describes a stage 3 pressure injury with full-thickness skin loss exposing adipose tissue. Choice D is incorrect as it describes a stage 4 pressure injury with full-thickness skin loss exposing bone. Thus, choice C is the most appropriate finding for a stage 2 pressure injury.