Difficulty: Medium
Average Score: 71%
Simulated
When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a stage pressure ulcer.
Correct answer
D
Rationale
The correct answer is D: 2. A stage 2 pressure ulcer involves partial-thickness skin loss involving the epidermis and/or dermis. In this scenario, the nurse notes a 3 cm area of partial-thickness skin loss resembling a blister on the sacral area, which fits the criteria for a stage 2 pressure ulcer. Choice A (4) involves full-thickness tissue loss, which is not the case here. Choice B (3) involves full-thickness tissue loss with damage to muscle or bone, which is more severe than the described scenario. Choice C (1) involves non-blanchable erythema, which is not indicative of partial-thickness skin loss. Therefore, choice D is the correct answer based on the characteristics of the wound described in the question.