A nurse is caring for a client who has a non-healing pressure injury on the right ankle.
Which action would the nurse take first?

Choice A rationale

The 44-year-old client with pneumonia receiving intravenous antibiotics is at some risk due to potential immobility and fever, which can lead to diaphoresis and skin maceration. However, this client is likely mobile enough to shift positions independently or with minimal assistance, reducing the risk of sustained pressure. The client's age and general health status, aside from the acute infection, suggest good tissue perfusion and skin integrity.

Choice B rationale

A 26-year-old who is bedridden with a fractured leg is at significant risk due to immobility. The inability to shift weight and relieve pressure on bony prominences can lead to ischemia and tissue damage. However, younger individuals generally have better vascular supply, skin turgor, and faster cellular regeneration compared to older adults, which provides some protective physiological advantage against pressure injury development.

Choice C rationale

This 65-year-old client is at the greatest risk due to a combination of multiple risk factors. Hemiparesis leads to immobility and the inability to reposition, causing prolonged pressure on one side of the body. Incontinence exposes the skin to moisture and chemical irritants from urine and feces, leading to maceration and a breakdown of the skin's protective barrier, making it more susceptible to injury.

Choice D rationale

A 78-year-old requiring a walker for ambulation is at a lower risk for pressure injuries compared to a bedridden individual. Although advanced age and the need for assistive devices suggest some mobility limitations, the ability to ambulate, even with assistance, indicates the capacity to shift weight and relieve pressure on a regular basis. This regular movement promotes circulation and prevents prolonged periods of immobility.

Choice A rationale

Assessing the client's support system is a valuable step, but it is not the best initial action. Overwhelmed clients need to feel a sense of control over their situation before they can effectively utilize external support. Focusing on one manageable change empowers the client, which is a more immediate and effective intervention for dealing with feelings of being overwhelmed.

Choice B rationale

Overwhelmed clients often feel a lack of control and competence. By assisting the client to identify and focus on a single, achievable lifestyle change, the nurse can help the client experience a sense of mastery and success. This positive experience can build confidence and motivation, making it more likely for the client to attempt and sustain further lifestyle changes.

Choice C rationale

While understanding a client's stressors is important for holistic care, this information may further overwhelm a client who is already feeling burdened. The immediate priority is to help the client feel capable of making a change. By first focusing on one small, manageable step, the nurse can begin to empower the client and then address broader stressors later.

Choice D rationale

Inquiring about delegating obligations may not be practical or appropriate for many clients and does not directly address the core issue of feeling overwhelmed by lifestyle changes. This suggestion externalizes the problem and does not empower the client to take control of their health. The focus should be on internal motivation and self-efficacy, not simply shifting responsibilities.