Question

the nurse assesses a bed - bound older adult client in the clients home. while assessing the clients buttocks, the nurse observes that an area of the skin is broken. the wound is shallow and dry, and there is no bruising. the nurse should document the clients pressure injury as stage iii. stage iv. stage ii. stage i.

Explanation:

Stage II pressure injury has partial - thickness skin loss, like a shallow open ulcer. Given the description of a broken, shallow, dry skin with no bruising, it fits stage II.

Answer:

stage II.