The nurse notes a client's skin is reddened with a small abrasion and serous fluid present.The nurse should classify this stage of ulcer formation as:

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This description is consistent with a stage II pressure ulcer.A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis.The ulcer is superficial and presents clinically as an abrasion,blister,or shallow crater.A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature,tissue consistency,and/or sensation.A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to,but not through,underlying fascia.A stage IV pressure ulcer has full-thickness skin loss with extensive destruction,tissue necrosis,or damage to muscle,bone,or supporting structures.

The Nurse Notes a Client's Skin Is Reddened with a Small