National Physical Therapy Examination (NPTE) Practice Exam

What characteristic defines stage II pressure wounds?

1. Full thickness tissue loss

2. Only redness without skin loss

3. Partial-thickness tissue loss

4. Undermining of tissue present

The correct answer is: Partial-thickness tissue loss

Stage II pressure wounds are characterized by partial-thickness tissue loss of the dermis. This can manifest as a shallow open ulcer with a red or pink wound bed, or as an intact or ruptured serum-filled blister. The key factor of partial-thickness means that the damage does not extend through the entire thickness of the skin, allowing some skin structures to remain intact. This is an important distinction because it informs treatment and management strategies, which may include maintaining a moist wound environment and protecting the area from further pressure or injury. In contrast, full-thickness tissue loss or undermining pertains to more severe stages, where the wound extends deeper into the tissue layers, possibly involving the subcutaneous tissue or beyond. Options that refer only to redness without skin loss or to the presence of undermining relate to different stages or descriptions of pressure injuries and do not accurately define the characteristics of stage II wounds. Thus, recognizing the specific definition surrounding partial-thickness tissue loss is crucial for understanding the appropriate classification of pressure wounds and facilitating accurate treatment interventions.