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    Ati Nur 213 Lifespan 3 Proctored Exam(Fundamental Exam)

    A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

    Explanation & Rationale

    A. Intact skin with localized erythema: This description aligns more with stage 1 pressure injuries, where there is non-blanchable erythema without any skin breakdown. B. Partial-thickness skin loss with red tissue in wound bed: Stage 2 pressure injuries involve partial-thickness skin loss, which may affect the epidermis and possibly the dermis. The wound bed typically shows red, viable tissue, and may present as a shallow open ulcer with a pink or red wound bed. C. Full thickness skin loss with visible bone: This describes a stage 4 pressure injury, where there is full-thickness tissue loss with exposed bone, tendon, or muscle. D. Full thickness skin loss with visible adipose tissue: This describes a stage 3 pressure injury, where there is full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, but without exposure of bone or muscle.

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