Which client is at the greatest risk for pressure injury development?

Choice A reason: Inflammatory is the phase of wound healing that occurs at the time of injury and lasts about 35 days, because it is the first and immediate response to tissue damage. Inflammatory is the phase of wound healing that involves the activation of the immune system, the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of a clot. Inflammatory is the phase of wound healing that aims to control bleeding, prevent infection, and prepare the wound for healing.

Choice B reason: Proliferative is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the inflammatory phase and lasts about 23 weeks. Proliferative is the phase of wound healing that involves the growth and multiplication of new cells, the formation of granulation tissue, the synthesis of collagen, the contraction of the wound edges, and the development of epithelial tissue. Proliferative is the phase of wound healing that aims to fill the wound, restore the strength, and cover the defect.

Choice C reason: Maturation is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the proliferative phase and lasts about several months to years. Maturation is the phase of wound healing that involves the remodeling and reorganization of the collagen fibers, the reduction of scar tissue, the improvement of elasticity, and the restoration of function. Maturation is the phase of wound healing that aims to refine the wound, enhance the quality, and optimize the outcome.

Choice D reason: Intentional is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather a classification of wound healing that depends on the type and extent of tissue damage, the degree of contamination, and the method of closure. Intentional is a classification of wound healing that refers to wounds that are surgically created, have minimal tissue loss, are clean and sterile, and are closed by primary intention, which means that the wound edges are approximated with sutures, staples, or glue. Intentional is a classification of wound healing that results in faster healing, less scarring, and lower risk of infection.

Choice A reason: The client is in a private room is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should be in a private room, as it can reduce the exposure to pathogens or allergens that may cause infection or inflammation. The client with reduced immunity has a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection. The private room can also provide privacy, comfort, and security for the client.

Choice B reason: The client has a dedicated vital signs machine is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have a dedicated vital signs machine, as it can prevent the crosscontamination or transmission of pathogens or allergens that may cause infection or inflammation. The vital signs machine is a device that measures the blood pressure, pulse, temperature, and oxygen saturation of the client. The vital signs machine can be contaminated by the blood, body fluids, or secretions of the client or other clients, and can harbor bacteria, viruses, or fungi. The dedicated vital signs machine can also ensure the accuracy, consistency, and availability of the measurements for the client.

Choice C reason: The client has a vase of fresh flowers on the table is an observation that requires further action by the nurse, because it is inappropriate and undesirable. The client with reduced immunity should not have a vase of fresh flowers on the table, as it can increase the exposure to pathogens or allergens that may cause infection or inflammation. The fresh flowers are a source of mold, pollen, or insects, which can trigger allergic reactions, respiratory distress, or skin irritation. The fresh flowers can also contain bacteria, viruses, or fungi, which can infect the client through inhalation, ingestion, or contact. The vase of fresh flowers should be removed from the room and replaced with artificial flowers, pictures, or cards.

Choice D reason: There is hand sanitizer by the door is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have hand sanitizer by the door, as it can promote the hand hygiene and infection prevention of the client and others. Hand sanitizer is a product that contains alcohol or other agents that can kill or reduce the number of pathogens or allergens that may cause infection or inflammation. Hand sanitizer should be used by the client, the staff, and the visitors before and after entering or leaving the room, or after touching any objects or surfaces in the room.