A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge?

Choice A rationale

There is no conclusive scientific evidence to support the claim that specific foods like chocolate, peanuts, and cola directly cause or worsen acne. Acne is a multifactorial condition primarily driven by hormonal changes, sebum production, follicular hyperkeratinization, and the bacteria Propionibacterium acnes. While a high glycemic diet may be linked to acne, there is no direct causal link with these specific foods.

Choice B rationale

Over-washing the face with harsh cleansing products can strip the skin of its natural oils (sebum), leading to a rebound effect where the sebaceous glands produce even more oil. This can exacerbate acne by creating a more favorable environment for bacterial proliferation and follicular clogging. Gentle cleansing twice a day is recommended, not frequent washing, to maintain skin barrier integrity.

Choice C rationale

Moderate sun exposure can be beneficial for some individuals with acne. Ultraviolet (UV) light has anti-inflammatory and antibacterial properties that can reduce the population of Propionibacterium acnes. Avoiding sun exposure completely is not a standard recommendation for acne prevention, although excessive sun exposure can lead to other skin problems and should be avoided.

Choice D rationale

Stress and lack of rest can increase cortisol levels, which can stimulate sebum production and inflammation, contributing to acne formation. A balanced diet provides essential vitamins and minerals for skin health, and sufficient rest helps regulate hormonal balance. Promoting overall well-being through diet and rest indirectly supports skin health and can help in the prevention of acne.

While nutritional status is crucial for wound healing, and labs such as albumin (normal range 3.5-5.0 g/dL) and prealbumin (normal range 15-36 mg/dL) are important indicators, assessing the underlying cause of non-healing is a priority. Drawing labs is a subsequent step after a thorough assessment has been completed to rule out circulatory issues as the primary cause.

Choice B rationale

A wound culture is performed to identify pathogens that may be causing a non-healing wound. However, it should only be done after assessing for other potential causes, such as poor circulation, which can compromise the delivery of immune cells and antibiotics to the wound site, making it impossible for the wound to heal regardless of the presence of bacteria.

Choice C rationale

Elevating the foot may be beneficial for reducing edema if present, which can impede circulation. However, this intervention should be based on a comprehensive circulatory assessment. Without first assessing the vascular status of the leg, this action is premature and may not be the most critical first step to take in addressing the underlying problem.

Choice D rationale

Assessing the right leg for pulses, skin color, and temperature is the most critical first step. A non-healing wound on an extremity, particularly an ankle, may indicate underlying peripheral arterial disease. Inadequate blood flow compromises oxygen and nutrient delivery to the wound bed, preventing cellular repair and growth. Ruling out or identifying circulatory compromise is the initial priority.