Stage II ulcer is characterized by which of the following?

• A. Epidermis is broken, lesion is superficial with partial thickness skin loss, possible blister
• B. Nonblanchable erythema
• C. Full thickness skin loss with exposure of bone
• D. Eschar formation over area

Answer: (A)

Stage II ulcers involve partial-thickness skin loss that affects the epidermis and possibly the dermis. The wound is shallow and may appear as an open area with a red/pink wound bed or as a ruptured serum-filled blister; the surface is moist and there is no exposure of bone, tendon, or muscle. This matches the description of epidermis being broken with partial-thickness skin loss, and the note that a blister may be present fits Stage II. In contrast, a nonblanchable red area without skin break indicates Stage I, full-thickness loss with bone exposure describes Stage IV, and eschar over the area suggests an unstageable wound rather than Stage II.