When assessing a client's skin, the nurse finds clusters of lesions. How would the nurse document the lesions?

A. The potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L), so there is no immediate concern. There is no abnormality in this lab value that needs to be addressed in this context.
B. The client's prealbumin level is 10 mg/dL, which is below the normal range (15 to 36 mg/dL). This is concerning as it indicates poor nutritional status, which can affect wound healing. Prealbumin is a sensitive indicator of nutritional status and is important in assessing the client's ability to heal from a pressure injury.
C. The client's history of diabetes mellitus is significant in this case. Diabetes can affect circulation, impair wound healing, and increase the risk of infections. Poor blood sugar control can contribute to delayed wound healing, so this is an important factor to consider.
D. While hyperlipidemia can contribute to cardiovascular issues, it is less directly related to wound healing in this case compared to diabetes mellitus. Although important to manage, it is not the most pressing issue in this context.

E. At this time, the wound shows no signs of infection. The surrounding skin is inflamed and red, which could be a sign of irritation or early pressure injury development, but there is no indication of infection (such as purulent drainage, increased pain, or fever) noted in the nursing notes.
F. The client's pedal pulse in the left foot is weak (1+), which indicates decreased perfusion to that extremity. Impaired circulation is a concern, especially in a client with diabetes, as it can further complicate wound healing. This is a critical factor to monitor closely.
G. The client's fasting blood glucose is elevated at 186 mg/dL, above the normal range (74 to 106 mg/dL). Elevated blood glucose levels can impair wound healing and increase the risk of infection, particularly in a client with diabetes.

A. Tilting the head forward is not necessary for the otoscope exam.
B. Pulling the pinna up and back is used for older children and adults.
C. Releasing the pinna after inserting the speculum is unnecessary.
D. For young children under 3 years, the pinna should be pulled down and back to straighten the ear canal.