A nurse is assessing a patient at risk for pressure ulcers. Which interventions are appropriate for preventing pressure ulcers based on the information in the text?(Select all that apply)

Choice A rationale:

Coldness to the touch is not a characteristic symptom of partial-thickness skin loss involving the epidermis and/or dermis.

This symptom is more indicative of compromised blood flow, such as in arterial insufficiency, and is not specific to pressure ulcers.

Choice B rationale:

Redness around the wound is a characteristic symptom of partial-thickness skin loss (stage 2 pressure ulcer).

This redness is due to localized inflammation and represents damage to the epidermis and/or dermis, but it does not involve muscle or deeper tissues.

Choice C rationale:

Tenderness when touching the wound is an expected symptom in partial-thickness skin loss involving the epidermis and/or dermis (stage 2 pressure ulcer).

The presence of tenderness is indicative of ongoing tissue damage and inflammation in the affected area.

Choice D rationale:

The statement, "My wound is deep, down to the muscle," suggests a full-thickness wound (stage 3 or 4 pressure ulcer) where muscle and deeper tissues are involved.

This statement does not align with the description provided in the question, which specifies partial-thickness skin loss.

Choice A rationale:

Measuring the wound size and depth is an essential action during the assessment of a pressure ulcer.

It helps in determining the severity of the ulcer, tracking its progress, and planning appropriate wound care interventions.

Choice B rationale:

Administering pain management as needed is not specifically related to the assessment phase but is an important aspect of pressure ulcer management overall.

Pain management is crucial to ensure the patient's comfort and adherence to the treatment plan, but it is not a direct assessment action.

Choice C rationale:

Checking vital signs for signs of infection is an appropriate action during the assessment of a patient with a pressure ulcer.

Fever and other vital sign abnormalities may indicate the presence of an infection in the wound, which requires immediate attention.

Choice D rationale:

Assessing the patient's nutritional status is a critical part of the assessment process for a patient with a pressure ulcer.

Malnutrition can delay wound healing, so assessing nutritional needs and addressing deficiencies is essential.

Choice E rationale:

Ensuring proper mobility to prevent pressure on vulnerable areas is an appropriate action during the assessment.

Assessing the patient's mobility status helps in identifying areas at risk for pressure ulcers and developing preventive strategies.

However, this action may also extend beyond the assessment phase and involve ongoing care.