The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied.

How should the PN document this finding?

The correct answer isChoice B.

Choice B rationale:

The practical nurse (PN) should instruct the unlicensed assistive personnel (UAP) to keep the client's skin clean and dry. Proper skin care is essential for a client with urinary and fecal incontinence to prevent the development of pressure ulcers. Keeping the skin clean and dry helps reduce moisture-related skin breakdown.

Choice A rationale:

Encouraging the client to rest quietly in bed is not directly related to preventing pressure ulcers. While adequate rest is essential for overall health, it does not specifically address the risk of pressure ulcers in an incontinent client.

Choice C rationale:

Obtaining supplies for contact precautions is unrelated to the client's risk of developing a sacral pressure ulcer. Contact precautions are used to prevent the spread of infectious diseases and do not address skin integrity.

Choice D rationale:

Documenting any changes in skin integrity is important, but it is the responsibility of the healthcare team, including the PN. However, this response does not provide proactive measures to prevent the pressure ulcer from occurring in the first place, which is the primary concern in this situation.

The correct answer is choice B: Thinning of the skin with loss of elasticity.

Choice A rationale:

While a decreased ability to communicate can be a significant challenge in elderly clients, it is not the primary physical characteristic of aging that contributes to the risk of pressure ulcers. Pressure ulcers develop due to prolonged pressure on specific areas of the skin, leading to reduced blood flow and tissue damage.
Choice B rationale:

Thinning of the skin with loss of elasticity is a critical physical characteristic of aging that contributes to the risk of pressure ulcers. As the skin becomes thinner and less elastic with age, it becomes more susceptible to injury from pressure and shear forces, increasing the likelihood of developing pressure ulcers.

Choice C rationale:

A 16 percent increase in overall body fat does not directly contribute to the risk of pressure ulcers. While changes in body composition occur with aging, the primary risk factors for pressure ulcers are related to skin integrity and mobility, not body fat percentage.

Choice D rationale:

Calcium loss in the bones (osteoporosis) is not the main contributing factor to pressure ulcers. Osteoporosis primarily affects bone density and strength but does not directly influence the development of pressure ulcers.