26. A client has a pressure ulcer that extends into the dermis and subcutaneous tissue. Which stage of pressure ulcer formation should a nurse document?
26. A client has a pressure ulcer that extends into the dermis and subcutaneous tissue. Which stage of pressure ulcer formation should a nurse document?
Test-Taking Tip
Eliminate the two extremes: I and IV—from the superficial layer to the deepest layer affected. Decide whether it affects the top layer or past the top layer.
Content Area: Adult Health, Integumentary; Integrated Process: Nursing Process. Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
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Answer 1 is incorrect because with stage I there are only superficial changes in the skin. Answer 2 is incorrect because a stage II pressure ulcer is confined to the top layer of the skin. Answer 3 is correct because a stage III pressure ulcer extends past the top layer of the skin. Answer 4 is incorrect because a stage IV pressure ulcer extends into the muscle and bone.
