Which assessment finding indicates to the nurse that the patient is at high risk for developing a pressure injury?

Question

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Poor nutrition,specifically severe protein deficiency,causes soft tissue to become susceptible to breakdown.Serum protein level of 4.6 g/dL leads to edema or swelling,which contributes to problems with the transportation of oxygen and nutrients.A hospitalized adult with a score of 16 or below and an older adult at 18 or below are at risk for pressure injury development; a score of 22 does not place the patient at risk.Cetirizine is a nonsedating antihistamine medication that would not place the patient at risk for developing pressure injuries.Fasting serum glucose level of 84 mg/dL is within normal limits and does not indicate risk of pressure injury development.

Which Assessment Finding Indicates to the Nurse That the Patient