The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shearing. Which score will the nurse document for this patient?

A. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed. Pain is subjective and should always be believed and assessed rather than dismissed based on procedure type. This does not demonstrate critical thinking.

B. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked best in the past. This approach assesses the patient’s individual experience and applies personalized care, which is a hallmark of critical thinking.

C. Administering pain-relief medication according to what was given last shift. Pain levels fluctuate, and medication effectiveness must be reassessed each time. Simply repeating the previous shift’s orders does not involve critical thinking.

D. Offering pain-relief medications based on the provider’s orders. While following orders is necessary, critical thinking involves assessing the patient’s pain level and determining the most appropriate intervention rather than blindly administering medication.

A. Stage I Pressure Ulcer: A Stage III pressure ulcer does not regress to a Stage I as it heals. It retains its original staging classification.

B. Stage III Pressure Ulcer: While the ulcer was originally Stage III, documenting it this way without specifying healing progress does not accurately reflect its current condition.

C. Healing Stage III Pressure Ulcer: Pressure ulcers are documented at their worst stage, even as they heal. The correct terminology includes "healing" to show improvement.

D. Healing Stage II Pressure Ulcer: A Stage III ulcer does not become a Stage II ulcer as it heals; instead, it is called a healing Stage III pressure ulcer.