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A Client Has a Pressure Ulcer on the Medial Malleolus

Question 42

Multiple Choice

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

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