A nurse is providing care for clients on a medical-surgical unit.Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

Choice A rationaleA client who is ambulatory following a cardiac catheterization 4 hours ago has increased mobility, which reduces the risk of prolonged pressure on bony prominences. The short duration post-procedure and ability to ambulate make this client less susceptible to pressure ulcer development.Choice B rationalePostoperative delirium can lead to decreased mobility, increased agitation and friction against surfaces, and impaired ability to communicate discomfort or reposition themselves. These factors significantly increase the risk of prolonged pressure and subsequent pressure ulcer formation.Choice C rationaleProtein-calorie malnutrition results in decreased subcutaneous tissue and muscle mass, which normally provide cushioning over bony prominences. Poor nutritional status also impairs tissue repair and increases skin fragility, making the client highly susceptible to pressure ulcer development.Choice D rationaleRight-sided heart failure can cause fluid overload and peripheral edema, particularly in the lower extremities. This edema increases tissue fragility and reduces blood flow to the skin, making it more susceptible to breakdown and pressure ulcer formation, especially in areas with bony prominences like heels and ankles.Choice E rationaleWhile hyperglycemia in type 1 diabetes mellitus can impair wound healing and increase the risk of infection if a pressure ulcer develops, it is not a direct primary risk factor for the initial development of pressure ulcers. Immobility, malnutrition, and edema are more direct contributors to skin breakdown due to pressure.