A nurse is assessing an adolescent client whose parent has recently died.
Which of the following findings should the nurse expect?

Choice A rationale:

Increased collagen. Increased collagen is not a risk factor for pressure injuries. Collagen provides strength and support to the skin and tissues, which can be protective against pressure injuries by maintaining tissue integrity.

Choice B rationale:

Decreased circulation. Decreased circulation is a significant risk factor for pressure injuries. When blood flow to a specific area is reduced, it can lead to tissue ischemia, which makes the tissue more vulnerable to pressure damage. The lack of oxygen and nutrients from reduced circulation impairs the skin's ability to withstand pressure, increasing the risk of pressure injury development.

Choice C rationale:

Increased muscle mass. While having increased muscle mass can offer some protection against pressure injuries due to the added support and padding, it is not a primary risk factor for developing pressure injuries. In fact, individuals with increased muscle mass may be less prone to pressure injuries because their muscle tissue helps distribute pressure more evenly.

Choice D rationale:

Decreased serum calcium. Decreased serum calcium levels can affect muscle function and bone health but are not a direct risk factor for pressure injuries. Pressure injuries primarily result from sustained pressure on the skin and underlying tissues, often due to immobility and other factors. Calcium levels are not directly related to the development of pressure injuries.

Choice A rationale:

"Depends on their friends for emotional support.”. While it's common for adolescents to rely on their friends for emotional support, this behavior is not necessarily indicative of a problem. Depending on friends for emotional support can be a healthy part of adolescent development, and it does not specifically relate to the loss of a parent.

Choice B rationale:

"Clings to their caregiver.”. The correct answer, "Clings to their caregiver," is a common response to the loss of a parent in adolescence. When adolescents experience the death of a parent, they often feel a strong need for emotional support and security. They may cling to their remaining caregiver, seeking comfort and reassurance during this challenging time.

Choice C rationale:

"Exhibits toileting problems.”. Exhibiting toileting problems can be a potential response to stress and emotional distress, but it is not the most expected or specific finding when a parent has recently died. This behavior may be more common in younger children who are still developing their coping mechanisms.

Choice D rationale:

"Reports tightness in their chest.”. While emotional distress can manifest physically, such as chest tightness, it is not the most characteristic finding when a parent has recently died. Clinging to a caregiver and seeking emotional support are more typical responses in adolescents.