A nurse is caring for a patient who has impaired speech. What actions should the nurse take?

Choice A rationale

Full-thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not a stage 1 pressure injury.

Choice B rationale

Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not a stage 1 pressure injury.

Choice C rationale

In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Choice D rationale

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not a stage 1 pressure injury.

Choice A rationale

While a patient’s medication history can impact wound healing, in this case, there is no specific information provided about the patient’s medications that would suggest a delay in wound healing.

Choice B rationale

Although the patient’s cholesterol level is elevated, hyperlipidemia is not typically associated with delayed wound healing.

Choice C rationale

Prealbumin is a marker of nutritional status. A low prealbumin level, like in this patient, could indicate malnutrition, which can delay wound healing. Adequate nutrition is essential for wound healing as it provides the necessary building blocks for tissue repair.

Choice D rationale

The patient’s fasting glucose level is within the normal range, so it is unlikely to impact wound healing. While poorly controlled diabetes can delay wound healing, this patient’s diabetes appears to be well-controlled.