A nurse is collecting data on a client.
Which of the following findings increase the client's risk of a pressure injury?

E.

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of a pressure injury.

Choice B rationale:

Peripheral neuropathy can lead to a loss of sensation, which increases the risk of a pressure injury as the individual may not feel discomfort or recognize the need to reposition.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases pressure on certain areas of the body, reducing blood flow and leading to tissue damage.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue hypoxia and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is at the lower end of the normal range (15-36 mg/dL)2. Low prealbumin levels can indicate poor nutritional status, which is a risk factor for pressure injuries.

Choice A rationale:

Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice B rationale:

Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice C rationale:

Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale:

Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.