A client has a pressure ulcer on the medial malleolus.The client's skin is intact with purple discoloration and a blood-filled blister.When documenting this finding,which terminology is appropriate for the nurse to use?
A) Partial-thickness loss of dermis
B) Non-blanchable erythema
C) Suspected deep tissue injury
D) Full-thickness tissue loss

Question

Quizplus · Accepted Answer

A) A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Non-blanchable erythema refers to a Stage I ulcer. Partial-thickness loss of dermis refers to a Stage II ulcer. Full-thickness tissue loss refers to Stage III, IV, and unstageable ulcers.
B) A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Non-blanchable erythema refers to a Stage I ulcer. Partial-thickness loss of dermis refers to a Stage II ulcer. Full-thickness tissue loss refers to Stage III, IV, and unstageable ulcers.
C) A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Non-blanchable erythema refers to a Stage I ulcer. Partial-thickness loss of dermis refers to a Stage II ulcer. Full-thickness tissue loss refers to Stage III, IV, and unstageable ulcers.
D) A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Non-blanchable erythema refers to a Stage I ulcer. Partial-thickness loss of dermis refers to a Stage II ulcer. Full-thickness tissue loss refers to Stage III, IV, and unstageable ulcers.

A Client Has a Pressure Ulcer on the Medial Malleolus