A Nurse Documents a Stage 1 Pressure Ulcer on a Patient's

A nurse documents a stage 1 pressure ulcer on a patient's lateral malleolus.What assessment findings would indicate that this ulcer has progressed to stage II? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A) The subcutaneous fat layer is exposed.
B) A fluid-filled blister is present.
C) A shallow open ulcer is present.
D) There is an area of boggy purple skin on the bony prominence.
E) There is an area of skin that does not turn white with pressure.