A newly admitted client has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment.
What assessment parameters should the nurse include? Select all that apply.

Choice A rationale

Scales represent the accumulation of dead skin cells that flake off, a common secondary lesion in eczema resulting from the chronic inflammation and rapid skin cell turnover.

Choice B rationale

Erosion occurs when the superficial layer of skin is lost, typically due to scratching or friction in eczema, exposing the underlying epidermis and sometimes leading to infection.

Choice C rationale

Crusts form when serum, blood, or purulent exudate dries on the skin surface, often seen in eczema as a result of weeping lesions and subsequent drying.

Choice D rationale

Ulcers are deeper lesions extending into the dermis or subcutaneous tissue and are not typically associated with eczema. Eczema usually affects the epidermis, causing secondary lesions like scales, erosion, and crusts rather than deep tissue ulcers.

Choice A rationale

Palpating the client's skin for moisture, temperature, and texture is essential in wound management. This allows the nurse to assess for signs of infection or inflammation, which can affect the wound healing process. Moisture can indicate excessive drainage or sweating that might macerate the skin, while changes in temperature and texture can signify infection or poor blood flow.

Choice B rationale

While asking the client whether the wound bed or surrounding skin itches may provide some information about the client's comfort, it is not a primary intervention for wound management. Itching can be a sign of healing or irritation, but it does not provide direct information on the wound's condition.

Choice C rationale

Measuring and assessing the wound bed, size, edges, and margins are critical steps in wound management. This helps to determine the progression of healing, the presence of necrotic tissue, and any changes in the wound over time. Accurate measurement and documentation are essential for developing an appropriate care plan.

Choice D rationale

Evaluating the client's level of pain using a numeric value pain scale is important in wound management. Pain can indicate underlying issues such as infection, poor perfusion, or neuropathy. Assessing pain helps guide interventions to provide comfort and address any complications that may arise.

Choice E rationale

Reviewing the client's prothrombin time test and international normalized ratio is not a standard intervention for wound management. These tests are more relevant to assessing the client's coagulation status, which may be important for surgical or anticoagulant therapy but not directly for wound care.