A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

Choice A rationale:

Stage I Pressure ulcer - This choice is not correct because a Stage I pressure ulcer is characterized by intact skin with non-blanchable redness over a bony prominence. There is no partial-thickness skin loss at this stage.

Choice B rationale:

Stage II Pressure ulcer - This is the correct choice. A Stage II pressure ulcer involves partial-thickness skin loss that presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also manifest as an intact or open/ruptured serum-filled blister.

Choice C rationale:

Stage IV Pressure ulcer - This choice is not correct because a Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. There is no mention of such extensive tissue loss in the given scenario.

Choice D rationale:

Stage II Pressure ulcer - This choice is a duplicate of Choice B and is not correct for the reasons stated above.

Choice A rationale:

Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown in older adults who are immobile or have limited mobility. Prolonged pressure on certain areas can lead to ischemia and tissue damage, particularly over bony prominences. Repositioning helps to distribute pressure evenly, maintain circulation, and reduce the risk of pressure ulcers.

Choice B rationale:

Massage of bony prominences is not recommended as a preventive measure for skin breakdown. Massaging these areas can actually cause friction and shear forces, leading to further damage to the delicate skin of older adults. Gentle repositioning and maintaining proper skin hygiene are more effective strategies.

Choice C rationale:

While a diet high in protein is important for overall health, it is not a direct intervention for maintaining the integrity of the client's skin. Protein is necessary for wound healing and tissue repair, but it doesn't address the primary concern of preventing skin breakdown due to pressure.

Choice D rationale:

Applying cornstarch to keep the skin dry is not a recommended practice for preventing skin breakdown. Excessive moisture can contribute to skin breakdown, but cornstarch may not be the best solution. Proper hygiene, gentle cleansing, and appropriate use of moisture-barrier products are more effective in maintaining skin integrity.