The Nurse Assesses an Open Area Over a Client's Greater

question 17

Multiple Choice

The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter.The tissue around the area is edematous and feels boggy.The edges of the wound cup in toward the center.Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?

• A)There is undermining of adjacent tissues.
• B)The crater extends into the subcutaneous tissue.
• C)The joint capsule of the hip is visible.
• D)The ulcer has thick dark eschar over the top.

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