The nurse is assessing a skin lesion using the ABCDE criteria.
The nurse understands "C" stands for:

Choice A rationale

Functional incontinence occurs when an individual cannot reach the bathroom in time due to physical or cognitive limitations. It is not related to stress or pressure on the bladder but rather to external factors that impede timely access to toileting facilities.

Choice B rationale

Reflex incontinence is characterized by involuntary loss of urine due to a lack of signal awareness or detrusor muscle overactivity. It is typically associated with neurological conditions such as spinal cord injuries or multiple sclerosis. This type of incontinence does not involve stress-related triggers like coughing or sneezing.

Choice C rationale

Stress incontinence involves the involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or physical exertion. This type of incontinence is commonly seen in women, particularly after childbirth or during menopause, due to weakened pelvic floor muscles or sphincter dysfunction.

Choice D rationale

Urge incontinence is characterized by a sudden and intense urge to urinate, often resulting in involuntary urine leakage before reaching the bathroom. It is typically caused by overactive bladder muscles or nerve signals and is not specifically triggered by actions like coughing or sneezing.

Choice A rationale

Patches of eschar covering parts of the wound are characteristic of more advanced pressure ulcers, such as Stage III or IV, where necrotic tissue is present. Eschar is a dark, thick, leathery scab or crust that indicates deeper tissue damage and is not observed in Stage II pressure ulcers.

Choice B rationale

A Stage II pressure ulcer is characterized by partial thickness skin erosion with loss of the epidermis and dermis. It appears as a shallow open ulcer with a red-pink wound bed, indicating that the damage has not extended beyond these layers of skin.

Choice C rationale

When a pressure ulcer extends into the subcutaneous tissue, it is classified as a Stage III or IV ulcer, depending on the depth and extent of tissue involvement. Stage II ulcers are limited to the epidermis and dermis and do not reach the subcutaneous layer.

Choice D rationale

Intact skin that appears red but is not broken is indicative of a Stage I pressure ulcer, which represents the earliest stage of pressure injury. Stage I ulcers involve non-blanchable erythema (redness) but no open wound or skin erosion.

Choice E rationale

Open blister areas with a red-pink wound bed are characteristic of Stage II pressure ulcers. These ulcers exhibit partial thickness skin loss and can present as open or fluid-filled blisters with a visible wound bed.

Choice F rationale

Localized redness in light skin that blanches with fingertip pressure is typical of a Stage I pressure ulcer. Blanching erythema indicates that the skin is still viable and blood flow is present, which differentiates Stage I from more advanced stages of pressure injury.