A nurse is teaching a newly licensed nurse about reducing the risk for healthcare-associated infections.
Which of the following instructions should the nurse include?

Choice A rationale:

Full thickness skin loss with visible bone. This choice does not align with the description of a stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness skin loss, but they do not involve visible bone. This description corresponds to a more severe stage of pressure injury.

Choice B rationale:

Intact skin with localized erythema. This choice describes a normal skin condition with localized redness (erythema) but does not indicate the presence of a pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, which means there is a break in the skin integrity.

Choice C rationale:

Full thickness skin loss with visible adipose tissue. This description is more in line with a stage 3 pressure injury, not a stage 2 injury. In stage 3, there is full-thickness skin loss, and adipose tissue may become visible in the wound bed. However, in stage 2, the skin loss is partial-thickness, and the wound bed typically contains red tissue.

Choice D rationale:

Partial-thickness skin loss with red tissue in the wound bed. This choice is the correct description of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss with the presence of red or pink tissue in the wound bed. It signifies damage to the epidermis and possibly the dermis. .

Choice A rationale:

Fibromyalgia. Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain, fatigue, and tender points. It is not an example of acute pain. Acute pain typically has a sudden onset and is of limited duration.

Choice B rationale:

Peripheral neuropathy. Peripheral neuropathy can cause both acute and chronic pain, depending on the underlying cause. However, it is not a classic example of acute pain. Acute pain is usually associated with a specific injury or condition and has a sudden onset.

Choice C rationale:

Rheumatoid arthritis. Rheumatoid arthritis is a chronic autoimmune condition that can cause joint pain and inflammation. While it can have acute flares of pain, it is primarily considered a chronic condition. Acute pain typically results from injuries or conditions with a sudden onset.

Choice D rationale:

Surgical incision. This is the correct answer. A surgical incision represents a classic example of acute pain. It is a pain that results from a specific event, in this case, surgery, and typically has a well-defined onset and duration. Acute pain is often sharp and intense, and it resolves as the incision heals.