Which nursing observation would indicate that the patient was at risk for pressure injury formation?

Question

Quizplus · Accepted Answer

The presence and duration of moisture on the skin increase the risk of pressure injury formation by making it susceptible to injury.Moisture can originate from wound drainage,excessive perspiration,and fecal or urinary incontinence.Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened,which causes maceration.Eating a balanced diet is important for nutrition,but eating just two thirds of the meal does not indicate that the individual is at risk.A raised red rash on the leg is a concern and can affect the integrity of the skin,but it is located on the shin,which is not a high-risk area for skin breakdown.Pressure can influence capillary refill,leading to skin breakdown,but this capillary response is within normal limits.

Which Nursing Observation Would Indicate That the Patient Was at Risk