Hesi RN Exit Proctored Exam
A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?
Explanation & Rationale
A. Persistent redness over a bony prominence is often the first indicator of pressure injury and requires immediate attention to prevent further skin breakdown. B. A superficial pressure injury may be more advanced and not the earliest finding; defined margins suggest it has progressed beyond initial redness. C. Broken skin indicates a more developed injury rather than the initial warning sign. D. Thick, dry, and dark areas indicate tissue necrosis, suggesting a more severe stage of injury that has already progressed past early warning signs.
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