A Nurse Is Treating the Pressure Ulcer of an African

A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in this client?

A) Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact skin.
B) Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
C) Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or cooler as compared with adjacent tissue.
D) Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.